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Current Research and Scholarly Interests

My work focuses on the health of low-income, ethnic minority, and other medically underserved populations. A number of grants from NIH and other Federal and State agencies have supported my work which has a broad public health focus. A central feature of my work has been the combination of theoretical and scientific input with practical input from the community to understand behavioral, social, cultural, and economic determinants of health behaviors that are amenable to change. My work covers: cancer and cardiovascular disease health behaviors, risk factors, and outcomes (smoking, physical inactivity, poor nutrition, obesity, diabetes, hypertension); health status of ethnic minority and low socioeconomic groups; community-based intervention studies; and neighborhood influences on health. I have had a long term working partnership with the Monterey County Health Department. For the last 15 years I have had a research partnership with Drs. Jan and Kristina Sundquist at Lund University in Sweden where we have been funded by numerous NIH RO1 grants to conduct population-based clinical epidemiologic research.

My research is congruent with a number of public service activities, including the Stanford Medical Youth Science Program, an organization that I helped found that prepares high school students historically underrepresented in higher education for science and health careers.

Publications

Journal Articles

Abstract

Individual risk assessment and behavior change dominate the content of high school health education instruction whereas broader social, political, and economic factors that influence health-known as upstream causes-are less commonly considered. With input from instructors and students, we developed a 10-lesson experiential Public Health Advocacy Curriculum that uses classroom-based activities to teach high school students about the upstream causes of health and engages them in community-based health advocacy. The Curriculum, most suitable for health- or advocacy-related elective classes or after-school programs, may be taught in its entirety or as single lessons integrated into existing coursework. Although students at many schools are using the Curriculum, it has been formally evaluated with 110 predominantly Latino students at one urban and one semirural public high school in Northern California (six classes). In pre-post surveys, students showed highly significant and positive changes in the nine questions that covered the three main Curriculum domains (Upstream Causes, Community Exploration, and Public Health Advocacy), p values .02 to

Abstract

Early-term birth (gestational age, 37-38 weeks) has been associated with increased infant mortality relative to later-term birth, but mortality beyond infancy has not been studied. We examined the association between early-term birth and mortality through young adulthood.We conducted a national cohort study of 679,981 singleton births in Sweden in 1973-1979, followed up for all-cause and cause-specific mortality through 2008 (ages 29-36 years).There were 10,656 deaths in 21.5 million person-years of follow-up. Among those still alive at the beginning of each age range, early-term birth relative to those born at 39-42 weeks was associated with increased mortality in the neonatal period (0-27 days: adjusted hazard ratio = 2.18 [95% confidence interval = 1.89-2.51]), postneonatal period (28-364 days: 1.66 [1.44-1.92]), early childhood (1-5 years: 1.29 [1.10-1.51]), and young adulthood (18-36 years: 1.14 [1.05-1.24]), but not in late childhood/adolescence (6-17 years: 0.97 [0.84-1.12]). In young adulthood, early-term birth was strongly associated with death from congenital anomalies and endocrine disorders, especially diabetes (2.89 [1.54-5.43]).In this large national cohort study, early-term birth was independently associated with increased mortality in infancy, early childhood, and young adulthood. Lowest short-term and long-term mortality was among those born at 39-42 weeks.

Abstract

The food insecurity faced by many Native American communities has numerous implications for the health and welfare of families. To identify and address upstream causes of food insecurity in a rural California reservation, we conducted a community assessment using the Tool for Health and Resilience in Vulnerable Environments (THRIVE). Guided by a community-based participatory research orientation, the THRIVE tool was adapted using digital storytelling and implemented in a series of focus groups. As a result of the THRIVE assessment, community members identified racial injustice and physical and financial barriers to accessing healthy and culturally appropriate foods as areas of greatest importance. Subsequently, the project partnership developed policies to reduce identified barriers which included an integrated community supported agriculture and commodity food program, the introduction of Electronic Benefits Transfer and culturally appropriate foods at the local farmers' market and reallocation of shelf space at the grocery store to include vegetables and fruits as well as special foods for diabetics. Results suggest that a participatory research orientation coupled with the use of a culturally adapted THRIVE tool may be an effective means for identifying structural determinants of food insecurity and initiating novel policy interventions to reduce health disparities experienced by Native American communities.

Gestational Age at Birth and Mortality in Young AdulthoodJAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATIONCrump, C., Sundquist, K., Sundquist, J., Winkleby, M. A.2011; 306 (11): 1233-1240

Abstract

Preterm birth is the leading cause of infant mortality in developed countries, but the association between gestational age at birth and mortality in adulthood remains unknown.To examine the association between gestational age at birth and mortality in young adulthood.National cohort study of 674,820 individuals born as singletons in Sweden in 1973 through 1979 who survived to age 1 year, including 27,979 born preterm (gestational age <37 weeks), followed up to 2008 (ages 29-36 years).All-cause and cause-specific mortality.A total of 7095 deaths occurred in 20.8 million person-years of follow-up. Among individuals still alive at the beginning of each age range, a strong inverse association was found between gestational age at birth and mortality in early childhood (ages 1-5 years: adjusted hazard ratio [aHR] for each additional week of gestation, 0.92; 95% CI, 0.89-0.94; P < .001), which disappeared in late childhood (ages 6-12 years: aHR, 0.99; 95% CI, 0.95-1.03; P = .61) and adolescence (ages 13-17 years: aHR, 0.99; 95% CI, 0.95-1.03; P = .64) and then reappeared in young adulthood (ages 18-36 years: aHR, 0.96; 95% CI, 0.94-0.97; P < .001). In young adulthood, mortality rates (per 1000 person-years) by gestational age at birth were 0.94 for 22 to 27 weeks, 0.86 for 28 to 33 weeks, 0.65 for 34 to 36 weeks, 0.46 for 37 to 42 weeks (full-term), and 0.54 for 43 or more weeks. Preterm birth was associated with increased mortality in young adulthood even among individuals born late preterm (34-36 weeks, aHR, 1.31; 95% CI, 1.13-1.50; P < .001), relative to those born full-term. In young adulthood, gestational age at birth had the strongest inverse association with mortality from congenital anomalies and respiratory, endocrine, and cardiovascular disorders and was not associated with mortality from neurological disorders, cancer, or injury.After excluding earlier deaths, low gestational age at birth was independently associated with increased mortality in early childhood and young adulthood.

Abstract

Research has not firmly established whether living in a deprived neighborhood predicts the incidence and case fatality of coronary heart disease (CHD), and whether effects vary across sociodemographic groups.Prospective follow-up study of all Swedish women and men, aged 35 to 74 (1.9 million women, 1.8 million men). Women and men, without a history of CHD, were assessed on December 31, 1995, and followed from January 1, 1996 through December 31, 2000, for first fatal or nonfatal CHD event (130,024 cases); data were analyzed in 2006. Neighborhood-level deprivation (index of education, income, unemployment, welfare assistance) was categorized as low, moderate, and high deprivation.Age-standardized CHD incidence was 1.9 times higher for women and 1.5 times higher for men in high- versus low-deprivation neighborhoods; 1-year case fatality from CHD was 1.6 times higher for women and 1.7 times higher for men in high versus low deprivation neighborhoods. The higher incidence in more deprived neighborhoods was observed across all individual-level sociodemographic groups (age, marital status, family income, education, immigration status, mobility, and urban/rural status). In multilevel logistic regression models, neighborhood deprivation remained significantly associated with both CHD incidence and case fatality for women and men after adjusting for the seven sociodemographic factors (p values <0.01). Effects were slightly stronger for women than men in an ancillary analysis that tested for gender differences.The clustering of CHD and subsequent mortality among adults in deprived neighborhoods raises important clinical and public health concerns, and calls for a reframing of health problems to include neighborhood social environments, as they may affect health.

Abstract

This study examines changes in cancer-related health behaviors and risk factors (overweight/obesity, unhealthy diet, high alcohol use, and smoking), and screening practices related to cervical, breast, and colorectal cancer among Latinos of predominantly Mexican origin in Monterey County, California.Data is from two cross-sectional surveys, conducted in 1990 and 2000, that included 919 women and 774 men from a community sample, and 276 men from an agricultural labor camp sample (ages 18-64).Over the 10-year period, the prevalence of obesity increased by 48% among community women, 47% among community men, and 91% among labor camp men. Although consumption of fruits and vegetables remained low and consumption of fried foods remained high, other diet-related behaviors showed significant improvements (e.g. milk consumption shifted from whole-fat to lower-fat among women from the community and men from the labor camps, use of lard or meat fat when cooking decreased among women and men from the community). In addition, alcohol intake decreased among men from both samples, as did smoking among labor camp men. There were large improvements for annual pap and mammography screening (increases from 53 to 71% for pap testing, and from 15 to 53% for mammography screening) but annual blood stool testing remained infrequent and unchanged.These findings highlight the need for interventions and policies that improve knowledge, preventive care, and social environments to sustain improvements and address areas of special need in cancer prevention for Latinos, especially related to obesity and colorectal screening.

Influence of individual and neighbourhood socioeconomic status on mortality among black, Mexican-American, and white women and men in the United StatesJOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTHWinkleby, M. A., Cubbin, C.2003; 57 (6): 444-452

Abstract

s: This study examines the influence of individual and neighbourhood socioeconomic status (SES) on mortality among black, Mexican-American, and white women and men in the US. The authors had three study objectives. Firstly, they examined mortality rates by both individual level SES (measured by income, education, and occupational/employment status) and neighbourhood level SES (index of neighbourhood income/wealth, educational attainment, occupational status, and employment status). Secondly, they examined whether neighbourhood SES was associated with mortality after controlling for individual SES. Thirdly, they calculated the population attributable risk to estimate the reduction in mortality rates if all women and men lived in the highest SES neighbourhoods.National Health Interview Survey (1987-1994), linked with 1990 census tract (neighbourhood proxy) and mortality data through 1997.Nationally representative sample of 59 935 black, 19 201 Mexican-American, and 344 432 white men and women (six gender and racial/ethnic groups), aged 25-64 at interview.Mortality rates for all six gender and racial/ethnic groups were two to four times higher for those with the lowest incomes (lowest quartile) who lived in the lowest SES neighbourhoods (lowest tertile) compared with those with the highest incomes who lived in the highest SES neighbourhoods. For the six groups, the age adjusted mortality risk associated with living in the lowest SES neighbourhoods ranged from 1.43 to 1.61. The mortality risk decreased but remained significant (p values

Abstract

Teen Activists for Community Change and Leadership Education is designed to engage high school students living in low-income neighborhoods in community advocacy efforts to transform their schools and communities so they do not reinforce use of alcohol, tobacco, and other drugs. This nine month intervention for 116 freshmen and sophomores in and near San Jose, California consisted of 30-90 minute meetings. Social cognitive constructs of sense of community, perceived self-efficacy, outcome expectancies, incentive value, policy control, and leadership competence guided the program. No changes in individual use of alcohol, tobacco, and other drugs were observed by the end of the program, but improvements in community involvement and self-perception of many of the constructs were observed.

Abstract

Cardiovascular disease (CVD) risk factors are higher among ethnic minority women than among white women in the United States. However, because ethnic minority women are disproportionately poor, socioeconomic status (SES) may substantially explain these risk factor differences.To determine whether differences in CVD risk factors by ethnicity could be attributed to differences in SES.Third National Health and Nutrition Examination Survey conducted between 1988 and 1994.Eighty-nine mobile examination centers.A total of 1762 black, 1481 Mexican American, and 2023 white women, aged 25 to 64 years, who completed both the home questionnaire and medical examination.Ethnicity and years of education (SES) in relation to systolic blood pressure, cigarette smoking, body mass index (BMI, a measure of weight in kilograms divided by the square of height in meters), physical inactivity, non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]), and non-insulin-dependent diabetes mellitus.As expected, most CVD risk factors were higher among ethnic minority women than among white women. After adjusting for years of education, highly significant differences in blood pressure, BMI, physical inactivity, and diabetes remained for both black and Mexican American women compared with white women (P

Abstract

This study was undertaken to test the effectiveness of the Stanford Nutrition Action Program, an experimental trial to reduce dietary fat intake among low-literacy, low-income adults.Twenty-four paired adult education classes (351 participants, 85% women, mean age = 31 years) were randomly assigned to receive a newly developed dietary fat curriculum (the Stanford Nutrition Action Program) or an existing general nutrition curriculum. Food frequency and nutrition-related data, body mass index, and capillary blood cholesterol were collected at baseline and at two postintervention follow-ups.The Stanford Nutrition Action Program classes showed significantly greater net improvements in nutrition knowledge (+7.7), attitudes (/0.2), and self-efficacy (-0.2) than the general nutrition classes; they also showed significantly greater reductions in the percentage of calories from total (-2.3%) and saturated (-0.9%) fat. There were no significant differences in body mass index or blood cholesterol. All positive intervention effects were maintained for 3 months postintervention.The Stanford Nutrition Action Program curriculum, tailored to the cultural, economic, and learning needs of low-literacy, low-income adults, was significantly more effective in achieving fat-related nutritional changes than the general nutrition curriculum.

Abstract

During the 1980s three comprehensive community-based heart disease prevention trials were conducted in the United States. The Stanford Five-City Project, Minnesota Heart Health Program, and Pawtucket Heart Health Program involved 12 cities; six received a 5-8 year multifactorial risk reduction program. This analysis pools data from the three studies to delineate the common intervention effects with greater sample size and power than could be attained by the single studies. Time trends were estimated for cigarette smoking, blood pressure, total cholesterol, body mass index, and coronary heart disease mortality risk in women and men aged 25-64 years. The joint estimates of intervention effect were in the expected direction in nine of 12 gender-specific comparisons; however, these were not statistically significant. The results illustrate the analytic challenges of evaluating community-based prevention trials and point to the smaller than expected net differences, rather than small sample size, as the reason for few statistically significant effects in the three U.S. prevention trials.

Abstract

This study examined long-term effects of a health-education intervention trial to reduce the risk of cardiovascular disease.Surveys were conducted in California in two treatment and two control cities at baseline (1979/1980), after the 6-year intervention (1985/1986), and 3 years later at follow-up (1989/1990). Net treatment/control differences in risk-factor change were assessed for women and men 25 to 74 years of age.Blood pressure improvements observed in all cities from baseline to the end of the intervention were maintained during the follow-up in treatment but not control cities. Cholesterol levels continued to decline in all cities during follow-up. Smoking rates leveled out or increased slightly in treatment cities and continued to decline in control cities but did not yield significant net differences. Both coronary heart disease and all-cause mortality risk scores were maintained or continued to improve in treatment cities while leveling out or rebounding in control cities.These findings suggest that community-based cardiovascular disease prevention trials can have sustained effects. However, the modest net differences in risk factors suggest the need for new designs and interventions that will accelerate positive risk-factor change.

Abstract

Biomedical preparatory programs (pipeline programs) have been developed at colleges and universities to better prepare youth for entering science- and health-related careers, but outcomes of such programs have seldom been rigorously evaluated. We conducted a matched cohort study to evaluate the Stanford Medical Youth Science Program's Summer Residential Program (SRP), a 25-year-old university-based biomedical pipeline program that reaches out to low-income and underrepresented ethnic minority high school students. Five annual surveys were used to assess educational outcomes and science-related experience among 96 SRP participants and a comparison group of 192 youth who applied but were not selected to participate in the SRP, using ~2:1 matching on sociodemographic and academic background to control for potential confounders. SRP participants were more likely than the comparison group to enter college (100.0 vs. 84.4 %, p = 0.002), and both of these matriculation rates were more than double the statewide average (40.8 %). In most areas of science-related experience, SRP participants reported significantly more experience (>twofold odds) than the comparison group at 1 year of follow-up, but these differences did not persist after 2-4 years. The comparison group reported substantially more participation in science or college preparatory programs, more academic role models, and less personal adversity than SRP participants, which likely influenced these findings toward the null hypothesis. SRP applicants, irrespective of whether selected for participation, had significantly better educational outcomes than population averages. Short-term science-related experience was better among SRP participants, although longer-term outcomes were similar, most likely due to college and science-related opportunities among the comparison group. We discuss implications for future evaluations of other biomedical pipeline programs.

Abstract

Perinatal factors including high birth weight have been found to be associated with acute lymphoblastic leukemia (ALL) in case-control studies. However, to the best of our knowledge, these findings have seldom been examined in large population-based cohort studies, and the specific contributions of gestational age and fetal growth remain unknown.The authors conducted a national cohort study of 3,569,333 individuals without Down syndrome who were born in Sweden between 1973 and 2008 and followed for the incidence of ALL through 2010 (maximum age, 38 years) to examine perinatal and familial risk factors.There were 1960 ALL cases with 69.7 million person-years of follow-up. After adjusting for potential confounders, risk factors for ALL included high fetal growth (incidence rate ratio [IRR] per additional 1 standard deviation, 1.07; 95% confidence interval [95% CI], 1.02-1.11 [P =.002]; and IRR for large vs appropriate for gestational age, 1.22; 95% CI, 1.06-1.40 [P =.005]), first-degree family history of ALL (IRR, 7.41; 95% CI, 4.60-11.95 [P

Abstract

Perinatal factors including high birth weight have been associated with childhood brain tumors in case-control studies. However, the specific contributions of gestational age and fetal growth remain unknown, and these issues have never been examined in large cohort studies with follow-up into adulthood. We conducted a national cohort study of 3,571,574 persons born in Sweden in 1973-2008, followed up for brain tumor incidence through 2010 (maximum age 38 years) to examine perinatal and familial risk factors. There were 2,809 brain tumors in 69.7 million person-years of follow-up. After adjusting for potential confounders, significant risk factors for brain tumors included high fetal growth (incidence rate ratio [IRR] per additional 1 standard deviation, 1.04; 95% CI, 1.01-1.08, P=0.02), first-degree family history of a brain tumor (IRR, 2.43; 95% CI, 1.86-3.18, P<0.001), parental country of birth (IRR for both parents born in Sweden vs. other countries, 1.21; 95% CI, 1.09-1.35, P<0.001), and high maternal education level (Ptrend=0.01). These risk factors did not vary by age at diagnosis. The association with high fetal growth appeared to involve pilocytic astrocytomas, but not other astrocytomas, medulloblastomas, or ependymomas. Gestational age at birth, birth order, multiple birth, and parental age were not associated with brain tumors. In this large cohort study, high fetal growth was associated with an increased risk of brain tumors (particularly pilocytic astrocytomas) independently of gestational age, not only in childhood but also into young adulthood, suggesting that growth factor pathways may play an important long-term role in the etiology of certain brain tumor subtypes.

Abstract

Ultraviolet radiation (UVR) exposure is the main risk factor for cutaneous malignant melanoma (CMM), but its specific effect in infancy is unknown. We examined whether season of birth, a proxy for solar UVR exposure in the first few months of life, is associated with CMM in childhood through young adulthood.National cohort study of 3 571 574 persons born in Sweden in 1973-2008, followed up for CMM incidence through 2009 (maximum age 37 years) to examine season of birth and other perinatal factors.There were 1595 CMM cases in 63.9 million person-years of follow-up. We found a sinusoidal pattern in CMM risk by season of birth (P = 0.006), with peak risk corresponding to birthdates in spring (March-May). Adjusted odds ratios for CMM by season of birth were 1.21 [95% confidence interval (CI), 1.05-1.39; P = 0.008] for spring, 1.07 (95% CI, 0.92-1.24; P = 0.40) for summer and 1.12 (95% CI, 0.96-1.29; P = 0.14) for winter, relative to fall. Spring birth was associated with superficial spreading subtype of CMM (P = 0.02), whereas there was no seasonal association with nodular subtype (P = 0.26). Other CMM risk factors included family history of CMM in a sibling (>6-fold) or parent (>3-fold), female gender, high fetal growth and high paternal education level.In this large cohort study, persons born in spring had increased risk of CMM in childhood through young adulthood, suggesting that the first few months of life may be a critical period of UVR susceptibility. Sun avoidance in early infancy may play an important role in the prevention of CMM in high-risk populations.

Abstract

The majority of ovarian tumors in girls and young women are nonepithelial in origin. The etiology of nonepithelial ovarian tumors remains largely unknown, and intrauterine exposures may play an important role. We examined the association of perinatal factors with risk of nonepithelial ovarian tumors in girls and young women.National cohort study of 1,536,057 women born in Sweden during 1973-2004 and followed for diagnoses of nonepithelial ovarian tumors through 2009 (attained ages 5-37years). Perinatal and maternal characteristics, and cancer diagnoses were ascertained using nationwide health registry data.147 women were diagnosed with nonepithelial ovarian tumors in 31.6 million person-years of follow-up, including 94 with germ cell tumors and 53 with sex-cord stromal tumors. Women born preterm (<37weeks of gestation) had significantly increased risk of developing nonepithelial ovarian tumors (adjusted hazard ratio 1.86, 95% CI 1.03-3.37; p=0.04). Histological subgroup analyses showed that preterm birth was associated with increased risk of sex-cord stromal tumors (4.39, 2.12-9.10; p<0.001), but not germ cell tumors (0.68, 0.21-2.15; p=0.51). No significant associations were found with fetal growth, birth order, and maternal age at birth.This large cohort study provides the first evidence that preterm birth is a risk factor for developing sex cord-stromal tumors. Ovarian hyperstimulation in response to high gonadotropin levels in preterm girls could mediate disease risk through the proliferative and steroidogenic effects of FSH and LH on granulosa and theca cells, from which most sex-cord stromal tumors are derived.

Abstract

Research is limited on the independent and joint effects of individual- and neighborhood-level socioeconomic status (SES) on breast cancer survival across different racial/ethnic groups.We studied individual-level SES, measured by self-reported education, and a composite neighborhood SES (nSES) measure in females (1,068 non-Hispanic whites, 1,670 Hispanics, 993 African-Americans, and 674 Asian-Americans), ages 18 to 79 years and diagnosed 1995 to 2008, in the San Francisco Bay Area. We evaluated all-cause and breast cancer-specific survival using stage-stratified Cox proportional hazards models with cluster adjustment for census block groups.In models adjusting for education and nSES, lower nSES was associated with worse all-cause survival among African-Americans (P trend = 0.03), Hispanics (P trend = 0.01), and Asian-Americans (P trend = 0.01). Education was not associated with all-cause survival. For breast cancer-specific survival, lower nSES was associated with poorer survival only among Asian-Americans (P trend = 0.01). When nSES and education were jointly considered, women with low education and low nSES had 1.4 to 2.7 times worse all-cause survival than women with high education and high nSES across all races/ethnicities. Among African-Americans and Asian-Americans, women with high education and low nSES had 1.6 to 1.9 times worse survival, respectively. For breast cancer-specific survival, joint associations were found only among Asian-Americans with worse survival for those with low nSES regardless of education.Both neighborhood and individual SES are associated with survival after breast cancer diagnosis, but these relationships vary by race/ethnicity.A better understanding of the relative contributions and interactions of SES with other factors will inform targeted interventions toward reducing long-standing disparities in breast cancer survival.

Abstract

Perinatal risk factors including high birth weight have been associated with Wilms tumor in case-control studies. However, these findings have seldom been examined in large cohort studies, and the specific contributions of gestational age at birth and fetal growth remain unknown. We conducted the largest population-based cohort study to date consisting of 3,571,574 persons born in Sweden in 1973-2008, followed up for Wilms tumor incidence through 2009 to examine perinatal risk factors. There were 443 Wilms tumor cases identified in 66.3 million person-years of follow-up. After adjusting for gestational age and other perinatal factors, high fetal growth was associated with increased risk of Wilms tumor among girls (hazard ratio per 1 standard deviation (SD), 1.36; 95 % CI 1.20-1.54; P

Abstract

BACKGROUND: More effective prevention of suicide requires a comprehensive understanding of sociodemographic, psychiatric and somatic risk factors. Previous studies have been limited by incomplete ascertainment of these factors. We conducted the first study of this issue using sociodemographic and out-patient and in-patient health data for a national population. Method We used data from a national cohort study of 7140589 Swedish adults followed for 8 years for suicide mortality (2001-2008). Sociodemographic factors were identified from national census data, and psychiatric and somatic disorders were identified from all out-patient and in-patient diagnoses nationwide. RESULTS: There were 8721 (0.12%) deaths from suicide during 2001-2008. All psychiatric disorders were strong risk factors for suicide among both women and men. Depression was the strongest risk factor, with a greater than 15-fold risk among women or men and even higher risks (up to 32-fold) within the first 3 months of diagnosis. Chronic obstructive pulmonary disease (COPD), cancer, spine disorders, asthma and stroke were significant risk factors among both women and men (1.4-2.1-fold risks) whereas diabetes and ischemic heart disease were modest risk factors only among men (1.2-1.4-fold risks). Sociodemographic risk factors included male sex, unmarried status or non-employment; and low education or income among men. CONCLUSIONS: All psychiatric disorders, COPD, cancer, spine disorders, asthma, stroke, diabetes, ischemic heart disease and specific sociodemographic factors were independent risk factors for suicide during 8 years of follow-up. Effective prevention of suicide requires a multifaceted approach in both psychiatric and primary care settings, targeting mental disorders (especially depression), specific somatic disorders and indicators of social support.

Abstract

The societal consequences of drug abuse (DA) are severe and well documented, the World Health Organization recommending tracking of population trends for effective policy responses in treatment of DA and delivery of health care services. However, to correctly identify possible sources of DA change, one must first disentangle three different time-related influences on the need for treatment due to DA: age effects, period effects and cohort effects.We constructed our main Swedish national DA database (spanning four decades) by linking healthcare data from the Swedish Hospital Discharge Register to individuals, which included hospitalisations in Sweden for 1975-2010. All hospitalized DA cases were identified by ICD codes. Our Swedish national sample consisted of 3078,129 men and 2921,816 women. We employed a cross-classified multilevel logistic regression model to disentangle any net age, period and cohort effects on DA hospitalization rates.We found distinct net age, period and cohort effects, each influencing the predicted probability of hospitalisation for DA in men and women. Peak age for DA in both sexes was 33-35 years; net period effects showed an increase in hospitalisation for DA from 1996 to 2001; and in birth cohorts 1968-1974, we saw a considerable reduction (around 75%) in predicted probability of hospitalisation for DA.The use of hospital admissions could be regarded as a proxy of the population's health service use for DA. Our results may thus constitute a basis for effective prevention planning, treatment and other appropriate policy responses.

Abstract

Mental disorders are associated with premature mortality, and the magnitudes of risk have commonly been estimated using hospital data. However, psychiatric patients who are hospitalized have more severe illness and do not adequately represent mental disorders in the general population. We conducted a national cohort study using outpatient and inpatient diagnoses for the entire Swedish adult population (N = 7,253,516) to examine the extent to which mortality risks are overestimated using inpatient diagnoses only. Outcomes were all-cause and suicide mortality during 8 years of follow-up (2001-2008). There were 377,339 (5.2%) persons with any inpatient psychiatric diagnosis, vs. 680,596 (9.4%) with any inpatient or outpatient diagnosis, hence 44.6% of diagnoses were missed using inpatient data only. When including and accounting for prevalent psychiatric cases, all-cause mortality risk among persons with any mental disorder was overestimated by 15.3% using only inpatient diagnoses (adjusted hazard ratio [aHR], 5.89; 95% CI, 5.85-5.92) vs. both inpatient and outpatient diagnoses (aHR, 5.11; 95% CI, 5.08-5.14). Suicide risk was overestimated by 18.5% (aHRs, 23.91 vs. 20.18), but this varied widely by specific disorders, from 4.4% for substance use to 49.1% for anxiety disorders. The sole use of inpatient diagnoses resulted in even greater overestimation of all-cause or suicide mortality risks when prevalent cases were unidentified (∼20-30%) or excluded (∼25-40%). However, different methods for handling prevalent cases resulted in only modest variation in risk estimates when using both inpatient and outpatient diagnoses. These findings have important implications for the interpretation of hospital-based studies and the design of future studies.

Abstract

Little is known about accidental death risks among psychiatric patients.To examine this issue in the most comprehensive study to date.National cohort study of all Swedish adults (n = 6 908 922) in 2001-2008.There were 22 419 (0.3%) accidental deaths in the total population, including 5933 (0.9%) accidental deaths v. 3731 (0.6%) suicides among psychiatric patients (n = 649 051). Of persons who died from accidents, 26.0% had any psychiatric diagnosis v. 9.4% in the general population. Accidental death risk was four- to sevenfold among personality disorders, six- to sevenfold among dementia, and two- to fourfold among schizophrenia, bipolar disorder, depression or anxiety disorders, and was not fully explained by comorbid substance use. Strong associations were found irrespective of sociodemographic characteristics, and for different types of accidental death (especially poisoning or falls).All mental disorders were strong independent risk factors for accidental death, which was substantially more common than suicide.

Abstract

IMPORTANCE Bipolar disorder is associated with premature mortality, but the specific causes and underlying pathways are unclear. OBJECTIVE To examine the physical health effects of bipolar disorder using outpatient and inpatient data for a national population. DESIGN, SETTING, AND PARTICIPANTS National cohort study of 6 587 036 Swedish adults, including 6618 with bipolar disorder. MAIN OUTCOMES AND MEASURES Physical comorbidities diagnosed in any outpatient or inpatient setting nationwide and mortality (January 1, 2003, through December 31, 2009). RESULTS Women and men with bipolar disorder died 9.0 and 8.5 years earlier on average than the rest of the population, respectively. All-cause mortality was increased 2-fold among women (adjusted hazard ratio [aHR], 2.34; 95% CI, 2.16-2.53) and men (aHR, 2.03; 95% CI, 1.85-2.23) with bipolar disorder, compared with the rest of the population. Patients with bipolar disorder had increased mortality from cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), influenza or pneumonia, unintentional injuries, and suicide for both women and men and cancer for women only. Suicide risk was 10-fold among women (aHR, 10.37; 95% CI, 7.36-14.60) and 8-fold among men (aHR, 8.09; 95% CI, 5.98-10.95) with bipolar disorder, compared with the rest of the population. Substance use disorders contributed only modestly to these findings. The association between bipolar disorder and mortality from chronic diseases (ischemic heart disease, diabetes, COPD, or cancer) was weaker among persons with a prior diagnosis of these conditions (aHR, 1.40; 95% CI, 1.26-1.56) than among those without a prior diagnosis (aHR, 2.38; 95% CI, 1.95-2.90; Pinteraction = .01). CONCLUSIONS AND RELEVANCE In this large national cohort study, patients with bipolar disorder died prematurely from multiple causes, including cardiovascular disease, diabetes, COPD, influenza or pneumonia, unintentional injuries, and suicide. However, chronic disease mortality among those with more timely medical diagnosis approached that of the general population, suggesting that better provision of primary medical care may effectively reduce premature mortality among persons with bipolar disorder.

Abstract

Preterm birth is associated with a number of physical and mental health issues. The aim of this study was to find out whether there was also any association between individuals born preterm in Sweden between 1984 and 2006 and the risk of unintentional injuries during childhood, adolescence and young adulthood.The study followed 2 297 134 individuals, including 5.9% born preterm, from 1985 to 2007 for unintentional injuries leading to hospitalization or death (n = 244 021). The males and females were divided into four age groups: 1-5 years, 6-12 years, 13-18 years and 19-23 years. Hazard ratios were calculated for falls, transport injuries and other injuries.After adjusting for a comprehensive set of covariates, some of the preterm subgroups demonstrated slightly increased risks of unintentional injuries, while others showed slightly decreased risks. However, most of the estimates were borderline or non-significant in both males and females. In addition, the absolute risk differences between individuals born preterm and full term were small.Despite the association between preterm birth and a variety of physical and mental health consequences, this study shows that there is no consistent risk pattern between preterm birth and unintentional injuries in childhood, adolescence and young adulthood.

Abstract

Schizophrenia is associated with premature mortality, but the specific causes and pathways are unclear. The authors used outpatient and inpatient data for a national population to examine the association between schizophrenia and mortality and comorbidities.This was a national cohort study of 6,097,834 Swedish adults, including 8,277 with schizophrenia, followed for 7 years (2003-2009) for mortality and comorbidities diagnosed in any outpatient or inpatient setting nationwide.On average, men with schizophrenia died 15 years earlier, and women 12 years earlier, than the rest of the population, and this was not accounted for by unnatural deaths. The leading causes were ischemic heart disease and cancer. Despite having twice as many health care system contacts, schizophrenia patients had no increased risk of nonfatal ischemic heart disease or cancer diagnoses, but they had an elevated mortality from ischemic heart disease (adjusted hazard ratio for women, 3.33 [95% CI=2.73-4.05]; for men, 2.20 [95% CI=1.83-2.65]) and cancer (adjusted hazard ratio for women, 1.71 [95% CI=1.38-2.10; for men, 1.44 [95% CI=1.15-1.80]). Among all people who died from ischemic heart disease or cancer, schizophrenia patients were less likely than others to have been diagnosed previously with these conditions (for ischemic heart disease, 26.3% compared with 43.7%; for cancer, 73.9% compared with 82.3%). The association between schizophrenia and mortality was stronger among women and the employed. Lack of antipsychotic treatment was also associated with elevated mortality.Schizophrenia patients had markedly premature mortality, and the leading causes were ischemic heart disease and cancer, which appeared to be underdiagnosed. Preventive interventions should prioritize primary health care tailored to this population, including more effective risk modification and screening for cardiovascular disease and cancer.

Abstract

To determine the risk of people with mental disorders being victims of homicide.National cohort study.Sweden.Entire adult population (n = 7,253,516).Homicidal death during eight years of follow-up (2001-08); hazard ratios for the association between mental disorders and homicidal death, with adjustment for sociodemographic confounders; potential modifying effect of comorbid substance use.615 homicidal deaths occurred in 54.4 million person years of follow-up. Mortality rates due to homicide (per 100,000 person years) were 2.8 among people with mental disorders compared with 1.1 in the general population. After adjustment for sociodemographic confounders, any mental disorder was associated with a 4.9-fold (95% confidence interval 4.0 to 6.0) risk of homicidal death, relative to people without mental disorders. Strong associations were found irrespective of age, sex, or other sociodemographic characteristics. Although the risk of homicidal death was highest among people with substance use disorders (approximately ninefold), the risk was also increased among those with personality disorders (3.2-fold), depression (2.6-fold), anxiety disorders (2.2-fold), or schizophrenia (1.8-fold) and did not seem to be explained by comorbid substance use. Sociodemographic risk factors included male sex, being unmarried, and low socioeconomic status.In this large cohort study, people with mental disorders, including those with substance use disorders, personality disorders, depression, anxiety disorders, or schizophrenia, had greatly increased risks of homicidal death. Interventions to reduce violent death among people with mental disorders should tackle victimisation and homicidal death in addition to suicide and accidents, which share common risk factors.

Abstract

The incidence of Hodgkin lymphoma has increased among adolescents and young adults in recent decades, but the relevant risk factors in early life are still unknown. A national cohort study was conducted of 3,571,574 individuals born in Sweden in 1973-2008 and followed up for Hodgkin lymphoma incidence through 2009, to examine perinatal and family risk factors for Hodgkin lymphoma in childhood through young adulthood (ages 0-37 years). There were 943 Hodgkin lymphoma cases identified in 66.3 million person-years of follow-up. High fetal growth was associated with an increased risk of Hodgkin lymphoma after adjustment for gestational age at birth and other potential confounders (P(trend) = 0.005). Family history of Hodgkin lymphoma in a sibling or parent also was strongly associated with an increased risk, with adjusted hazard ratios = 8.83 (95% confidence interval: 3.67, 21.30) and 7.19 (95% confidence interval: 3.58, 14.44), respectively. No association was found between gestational age at birth, birth order, twinning, parental age, or parental education and Hodgkin lymphoma. These findings did not vary by age at Hodgkin lymphoma diagnosis. Similar associations were found for nodular sclerosis and mixed cellularity subtypes. These findings suggest that perinatal factors including possible growth factor pathways may contribute to the risk of Hodgkin lymphoma in childhood through young adulthood.

Abstract

Most testicular germ cell tumors originate from carcinoma in situ cells in fetal life, possibly related to sex hormone imbalances in early pregnancy. Previous studies of association between gestational age at birth and testicular cancer have yielded discrepant results and have not examined extreme preterm birth. Our objective was to determine whether low gestational age at birth is independently associated with testicular cancer in later life. We conducted a national cohort study of 354,860 men born in Sweden in 1973-1979, including 19,214 born preterm (gestational age < 37 weeks) of whom 1,279 were born extremely preterm (22-29 weeks), followed for testicular cancer incidence through 2008. A total of 767 testicular cancers (296 seminomas and 471 nonseminomatous germ cell tumors) were identified in 11.2 million person-years of follow-up. Extreme preterm birth was associated with an increased risk of testicular cancer (hazard ratio = 3.95; 95% confidence interval = 1.67-9.34) after adjusting for other perinatal factors, family history of testicular cancer and cryptorchidism. Only five cases (three seminomas and two nonseminomas) occurred among men born extremely preterm, limiting the precision of risk estimates. No association was found between later preterm birth, post-term birth or low or high fetal growth and testicular cancer. These findings suggest that extreme but not later preterm birth may be independently associated with testicular cancer in later life. They are based on a small number of cases and will need confirmation in other large cohorts. Elucidation of the key prenatal etiologic factors may potentially lead to preventive interventions in early life.

Abstract

Prior research suggests that drug abuse (DA) is strongly influenced by both genetic and familial environmental factors. No large-scale adoption study has previously attempted to verify and integrate these findings.To determine how genetic and environmental factors contribute to the risk for DA.Follow-up in 9 public databases (1961-2009) of adopted children and their biological and adoptive relatives.Sweden.The study included 18 115 adopted children born between 1950 and 1993; 78,079 biological parents and siblings; and 51,208 adoptive parents and siblings.Drug abuse recorded in medical, legal, or pharmacy registry records.Risk for DA was significantly elevated in the adopted offspring of biological parents with DA (odds ratio, 2.09; 95% CI, 1.66-2.62), in biological full and half siblings of adopted children with DA (odds ratio, 1.84; 95% CI, 1.28-2.64; and odds ratio, 1.41; 95% CI, 1.19-1.67, respectively), and in adoptive siblings of adopted children with DA (odds ratio, 1.95; 95% CI, 1.43-2.65). A genetic risk index (including biological parental or sibling history of DA, criminal activity, and psychiatric or alcohol problems) and an environmental risk index (including adoptive parental history of divorce, death, criminal activity, and alcohol problems, as well as an adoptive sibling history of DA and psychiatric or alcohol problems) both strongly predicted the risk for DA. Including both indices along with sex and age at adoption in a predictive model revealed a significant positive interaction between the genetic and environmental risk indices.Drug abuse is an etiologically complex syndrome strongly influenced by a diverse set of genetic risk factors reflecting a specific liability to DA, by a vulnerability to other externalizing disorders, and by a range of environmental factors reflecting marital instability, as well as psychopathology and criminal behavior in the adoptive home. Adverse environmental effects on DA are more pathogenic in individuals with high levels of genetic risk. These results should be interpreted in the context of limitations of the diagnosis of DA from registries.

Abstract

The incidence of non-Hodgkin lymphoma (NHL) in early life has increased in recent decades, but the relevant risk factors remain largely unknown. We examined perinatal and family risk factors for NHL in childhood through young adulthood.We conducted a national cohort study of 3 571 574 individuals born in Sweden in 1973-2008 who were followed for incidence of NHL through 2009 (ages 0-37 years). Detailed information on perinatal and family characteristics and NHL diagnoses were obtained from national birth and cancer registries. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between perinatal and family variables and NHL; P values are from two-sided tests.There were 936 NHL case patients identified in 66.3 million person-years of follow-up. Independent risk factors for NHL included family history of NHL in either a sibling (adjusted HR = 9.84; 95% CI = 2.46 to 39.41; P = .001) or parent (adjusted HR = 2.36; 95% CI = 1.27 to 4.38; P = .007); high fetal growth (for ? 2 SDs relative to 0 to <1 SD from the mean: adjusted HR = 1.64; 95% CI = 1.19 to 2.25; P = .002); older maternal age (adjusted HR for each 5-year increment = 1.11; 95% CI = 1.04 to 1.19; P (trend) = .004); low birth order (adjusted HR for each increment of one birth = 0.91; 95% CI = 0.84 to 0.99; P (trend) = .02); and male sex (adjusted HR = 1.58; 95% CI = 1.38 to 1.80; P < .001). Male sex was associated with onset of NHL before 15 years of age but not with later-onset NHL, whereas the other risk factors did not vary by age at diagnosis. No association was found between gestational age at birth, twinning, paternal age, or parental education and NHL.In this large national cohort study, family history of NHL, high fetal growth, older maternal age, low birth order, and male sex were independent risk factors for NHL in early life.

Abstract

Preterm birth is associated with gastric acid-related disorders in infancy, but no investigators have examined this association beyond early childhood. We used antisecretory medication data to explore whether preterm birth is associated with gastric acid-related disorders in young adulthood.We conducted a national cohort study of 626,811 individuals born in Sweden in 1973 to 1979, followed up for antisecretory (proton pump inhibitor and H2-receptor antagonist) medication prescriptions from all outpatient and inpatient pharmacies nationwide from 2005 to 2009 (ages 25.5-37.0 years). We excluded individuals with congenital anomalies, and examined potential confounding by other comorbidities identified on the basis of oral anti-inflammatory or corticosteroid medication prescription.Gestational age at birth was inversely associated with antisecretory medication prescription in young adulthood. Adjusted odds ratios for ?1 antisecretory medication prescription/year were 3.38 (95% confidence interval [95% CI], 1.73-6.62) for individuals born at 22-27 weeks, 1.38 (95% CI, 1.19-1.60) for those born at 28-34 weeks, and 1.19 (95% CI, 1.06-1.32) for those born at 35-36 weeks, relative to those born full-term (37-42 weeks). Exclusion of individuals who were prescribed oral anti-inflammatory or corticosteroid medications (?1/year) had little effect on these results.These findings suggest that low gestational age at birth may be independently associated with an increased risk of gastric acid-related disorders in young adulthood.

Abstract

To determine whether preterm birth is associated with epilepsy in a national cohort of adults aged 25-37 years.We conducted a national cohort study of 630,090 infants born in Sweden from 1973 through 1979, including 27,953 born preterm (<37 weeks), followed from 2005 to 2009 for 1) hospitalization for epilepsy and 2) outpatient and inpatient prescription of antiepileptic drugs. Epilepsy diagnoses and medication data were obtained from all hospitals and pharmacies throughout Sweden.We found a strong association between preterm birth and epilepsy that increased by earlier gestational age. After adjusting for fetal growth and potential confounders, odds ratios for hospitalization for epilepsy were 4.98 (95%confidence interval [CI] 2.87-8.62) for those born at 23-31 weeks, 1.98 (95% CI 1.26-3.13) for those born at 32-34 weeks, and 1.76 (95% CI 1.30-2.38) for those born at 35-36 weeks, relative to those born full-term (37-42 weeks). A similar but slightly weaker trend was observed for the association between preterm birth and antiepileptic drug prescription. These associations persisted after excluding individuals with cerebral palsy, inflammatory diseases of the CNS, cerebrovascular disease, and brain tumors.These findings suggest that preterm birth, including late preterm birth, is strongly associated with epilepsy in Swedish adults aged 25-37 years. This association was independent of fetal growth and was not mediated by cerebral palsy or other comorbidities.

Abstract

The purpose of this study is to estimate the effect of education and income on incident heart failure (HF) hospitalization among post-menopausal women.Investigations of socioeconomic status have focused on outcomes after HF diagnosis, not associations with incident HF. We used data from the Women's Health Initiative Hormone Trials to examine the association between socioeconomic status levels and incident HF hospitalization.We included 26,160 healthy, post-menopausal women. Education and income were self-reported. Analysis of variance, chi-square tests, and proportional hazards models were used for statistical analysis, with adjustment for demographics, comorbid conditions, behavioral factors, and hormone and dietary modification assignments.Women with household incomes $50,000 a year (16.7/10,000 person-years; p < 0.01). Women with less than a high school education had higher HF hospitalization incidence (51.2/10,000 person-years) than college graduates and above (25.5/10,000 person-years; p < 0.01). In multivariable analyses, women with the lowest income levels had 56% higher risk (hazard ratio: 1.56, 95% confidence interval: 1.19 to 2.04) than the highest income women; women with the least amount of education had 21% higher risk for incident HF hospitalization (hazard ratio: 1.21, 95% confidence interval: 0.90 to 1.62) than the most educated women.Lower income is associated with an increased incidence of HF hospitalization among healthy, post-menopausal women, whereas multivariable adjustment attenuated the association of education with incident HF.

Abstract

Previous studies suggest that low birth weight is associated with thyroid autoimmunity and hypothyroidism in later life, but the potential effect of preterm birth, independent of foetal growth, is unknown. Our objective was to determine whether preterm birth is independently associated with medically treated hypothyroidism in young adulthood.National cohort study of 629,806 individuals born in Sweden from 1973 through 1979, including 27,935 born preterm (<37 weeks).Thyroid hormone prescription during 2005-2009 (ages 25·5-37·0 years), obtained from all outpatient and inpatient pharmacies throughout Sweden.Preterm birth was associated with increased relative odds of thyroid hormone prescription in young adulthood, after adjusting for foetal growth and other potential confounders. This association appeared stronger among twins than singletons (P = 0·04 for the interaction). Twins had increased relative odds across the full range of preterm gestational ages, whereas singletons had increased relative odds only if born very preterm (23-31 weeks). Among twins and singletons, respectively, adjusted odds ratios for individuals born preterm (<37 weeks) were 1·54 (95% CI, 1·11-2·14) and 1·08 (95% CI, 0·98-1·19), and for individuals born very preterm (23-31 weeks) were 2·62 (95% CI, 1·30-5·27) and 1·59 (95% CI, 1·18-2·14), relative to full-term births.This national cohort study suggests that preterm birth is associated with an increased risk of medically treated hypothyroidism in young adulthood. This association was independent of foetal growth and appeared stronger among twins than singletons. Additional studies are needed to confirm these new findings in other populations and to elucidate the mechanisms.

Abstract

Studies of adoptees have the potential to disentangle the contributions of genetic versus family environmental factors in the familial [corrected] transmission of coronary heart disease (CHD) because adoptees do not share the same family environment as their biological parents. The aims of this study were as follows: (1) to examine the risk of CHD in adopted men and women with at least one biological parent with CHD and (2) to examine the risk of CHD in adopted men and women with at least one adoptive parent with CHD.The Swedish Multigenerational register was used to follow all Swedish-born adoptees (born in or after 1932, n = 80,214) between January 1, 1973, and December 31, 2008, for CHD. The risk of CHD was estimated in adopted men and women with at least one biological parent with CHD and adopted men and women with at least one adoptive parent with CHD. The control groups consisted of adopted men or women without a biological parent with CHD or adopted men or women without an adoptive parent with CHD.Adopted men and women with at least one biological parent with CHD (n = 749) were 1.4 to 1.6 times (statistically significant, 95% CI) more likely to have CHD than adoptees without a biological parent with CHD. In contrast, men and women with at least one adoptive parent with CHD (n = 1,009) were not at increased risk of the disease.These findings (based on validated hospital diagnoses unbiased by recall) suggest that the familial [corrected] transmission of CHD from parents to offspring is more related to genetic factors than to family environmental factors.

Abstract

To document the prevalence of obese Mexican-Americans never advised by health professionals regarding exercise and diet, and to determine risk factors for no advice.Data came from 1787 obese Mexican-American adults (body mass index ?30; age ?18 years) in the Medical Expenditure Panel Survey. The survey included self-reported receipt of health care provider advice on exercise and diet as well as sociodemographic, health-related, and provider-related factors. Multivariable logistic regression models were performed separately for advice regarding exercise and advice regarding diet.Overall, 45% of respondents reported that they had never received advice from a doctor or health care professional to exercise more, and 52% reported that they have received advice to eat fewer higher-fat/high-cholesterol foods. Men, nonmarried respondents, lower-educated respondents, those who preferred to speak Spanish at home, and those without comorbid chronic conditions were less likely to receive advice.Results suggest that obese Mexican-Americans are insufficiently advised by health care providers regarding exercise and diet. Given the seriousness of obesity-related health risks and the increasing prevalence of overweight status and obesity among Mexican-Americans, it is vital that providers are involved in finding ways to effectively educate and/or treat overweight patients.

Abstract

The Kingdom of Saudi Arabia (KSA), similar to other countries in the Eastern Mediterranean, has been experiencing a recent rapid increase in the prevalence of chronic diseases and associated risk factors. To begin to take advantage of the chronic disease prevention and health promotion (CDPHP) knowledge available from other nations, researchers at a newly established University in the Qassim Province of the KSA have partnered with Stanford University in the United States of America. To ensure that CDPHP research and interventions are culturally relevant and appropriate, a participatory research approach has been adopted where local researchers are the target "community." Contextual challenges of conducting CDPHP research in the KSA, at the individual, social/cultural, organizational and environmental/policy levels, are identified, as well as examples of CDPHP intervention strategies that may be culturally appropriate at each level.

Abstract

Previous studies have suggested that preterm birth is associated with diabetes later in life. These studies have shown inconsistent results for late preterm births and have had various limitations, including the inability to evaluate diabetic outpatients or to estimate risk across the full range of gestational ages. Our objective was to determine whether preterm birth is associated with diabetes medication prescription in a national cohort of young adults.This was a national cohort study of 630,090 infants born in Sweden from 1973 through 1979 (including 27,953 born preterm, gestational age <37 weeks), followed for diabetes medication prescription in 2005-2009 (ages 25.5-37.0 years). Medication data were obtained from all outpatient and inpatient pharmacies throughout Sweden.Individuals born preterm, including those born late preterm (gestational age 35-36 weeks), had modestly increased odds ratios (ORs) for diabetes medication prescription relative to those born full term, after adjusting for fetal growth and other potential confounders. Insulin and/or oral diabetes medications were prescribed to 1.5% of individuals born preterm compared with 1.2% of those born full term (adjusted OR 1.13 [95% CI 1.02-1.26]). Insulin without oral diabetes medications was prescribed to 1.0% of individuals born preterm compared with 0.8% of those born full term (1.22 [1.08-1.39]).Preterm birth, including late preterm birth, is associated with a modestly increased risk of diabetes in young Swedish adults. These findings have important public health implications given the increasing number of preterm births and the large disease burden of diabetes, particularly when diagnosed in young adulthood.

Abstract

Previous studies of the association between gestational age or birth weight and allergic rhinitis in later life have had various limitations, including the inability to estimate risk among subjects born extremely preterm or to examine specific contributions of gestational age and fetal growth.We sought to determine whether gestational age at birth independent of fetal growth is associated with allergic rhinitis medication prescription in a national cohort of young adults.We conducted a national cohort study of 630,090 infants born in Sweden from 1973 through 1979 including 27,953 born preterm (<37 weeks) and followed for prescription of nasal corticosteroids and oral antihistamines in 2005-2009 (age, 25.5-37.0 years). Medication data were obtained from all outpatient and inpatient pharmacies throughout Sweden.The overall prevalence of nasal corticosteroid and oral antihistamine prescription was 16.3% and 16.8%, respectively, which is similar to the reported prevalence of allergic rhinitis in this population. Low gestational age at birth was associated with a decreased risk of nasal corticosteroid and oral antihistamine prescription in young adulthood after adjusting for fetal growth and other potential confounders. For subjects born extremely preterm (23-28 weeks), adjusted odds ratios were 0.70 (95% CI, 0.51-0.96) for nasal corticosteroid prescription and 0.45 (95% CI, 0.27-0.76) for both nasal corticosteroid and oral antihistamine prescription relative to those born at full term.These findings suggest that low gestational age at birth independent of fetal growth is associated with a decreased risk of allergic rhinitis in young adulthood, possibly because of a protective effect of earlier exposure to pathogens.

Abstract

This study examines whether neighbourhood deprivation increases the risk of giving birth to a small for gestational age (SGA) infant, after accounting for individual-level maternal socioeconomic characteristics.An open cohort of women, aged 20-44 years, was followed from 1 January 1992 through 31 December 2004 for first singleton births. The women's residential addresses during the two consecutive years preceding the birth of their infants were geocoded and classified into three levels of neighbourhood deprivation. Gestational age was confirmed by ultrasound examinations. Multilevel logistic regression models were used in the statistical analysis.Sweden.During the study period, women gave birth to 720 357 infants, of whom 20 487 (2.8%) were SGA. Age-adjusted incidence rates of SGA births increased with increasing level of neighbourhood deprivation. In the total population, 2.5% of births in the least deprived neighbourhoods and 3.5% of births in the most deprived neighbourhoods were SGA. A similar pattern of higher incidence with increasing level of neighbourhood-level deprivation was observed across all individual-level sociodemographic categories, including maternal age, marital status, family income, educational attainment, employment, mobility and urban/rural status. High neighbourhood-level deprivation remained significantly associated with SGA risk after adjusting for maternal sociodemographic characteristics (OR 1.28, 95% CI 1.22 to 1.34).This study is the largest to date of the influence of neighbourhood on SGA birth, with SGA confirmed by ultrasound examination. Results suggest that the characteristics of a mother's neighbourhood affect the risk of delivering an SGA infant independently of maternal sociodemographic characteristics.

Risk of Asthma in Young Adults Who Were Born Preterm: A Swedish National Cohort StudyPEDIATRICSCrump, C., Winkleby, M. A., Sundquist, J., Sundquist, K.2011; 127 (4): E913-E920

Abstract

Preterm birth is associated with asthma-like symptoms in childhood and possibly in adolescence, but the longer-term risk of asthma is unknown and increasingly relevant as larger numbers of these individuals enter adulthood. Our objective was to evaluate whether those who were born preterm are more likely to be prescribed asthma medications in young adulthood than those who were born term.We conducted a national cohort study of all singleton infants born in Sweden from 1973 through 1979 (n = 622 616), followed to ages 25.5 to 35.0 years to determine whether asthma medications were prescribed in 2005-2007. Asthma medication data were obtained from all outpatient and inpatient pharmacies throughout Sweden. To improve the positive predictive value for asthma, the outcome was defined as prescription of (1) both a ?-2 agonist inhalant and a glucocorticoid inhalant or (2) a combination inhalant containing a ?-2 agonist and other drugs for obstructive airway diseases.Young adults who were born extremely preterm (23-27 weeks' gestation) were 2.4 times more likely (adjusted 95% CI: 1.41-4.06) to be prescribed asthma medications than those who were born term. No association was found between later preterm birth (28-32 or 33-36 weeks' gestation) and asthma medications in young adulthood.This is the first study with sufficient statistical power to evaluate the risk of asthma beyond adolescence in individuals who were born extremely preterm. The results suggest that extreme preterm birth (23-27 weeks' gestation), but not later preterm birth, is associated with an increased risk of asthma at least into young adulthood.

Abstract

Previous studies of neighborhood deprivation and mental disorders have yielded mixed results, possibly because they were based on different substrata of the population. We conducted a national multilevel study to determine whether neighborhood deprivation is independently associated with psychiatric medication prescription in a national population.Nationwide outpatient and inpatient psychiatric medication data were analyzed for all Swedish adults (N = 6,998,075) after 2.5 years of follow-up. Multilevel logistic regression was used to estimate the association between neighborhood deprivation (index of education, income, unemployment, and welfare assistance) and prescription of psychiatric medications (antipsychotics, antidepressants, anxiolytics, or hypnotics/sedatives), after adjusting for broadly measured individual-level sociodemographic characteristics.For each psychiatric medication class, a monotonic trend of increasing prescription was observed by increasing level of neighborhood deprivation. The strongest associations were found for antipsychotics and anxiolytics, with adjusted odds ratios of 1.40 (95% confidence interval [CI], 1.36-1.44) and 1.24 (95% CI, 1.22-1.27), respectively, comparing the highest- to the lowest-deprivation neighborhood quintiles.These findings suggest that neighborhood deprivation is associated with psychiatric medication prescription independent of individual-level sociodemographic characteristics. Further research is needed to elucidate the mechanisms by which neighborhood deprivation may affect mental health and to identify the most susceptible groups in the population.

Risk of Hypertension Among Young Adults Who Were Born Preterm: A Swedish National Study of 636,000 BirthsAMERICAN JOURNAL OF EPIDEMIOLOGYCrump, C., Winkleby, M. A., Sundquist, K., Sundquist, J.2011; 173 (7): 797-803

Abstract

Previous studies have reported an association between preterm birth and elevated blood pressure in adolescence and young adulthood. These studies were based on single-day blood pressure measurements and had limited ability to estimate risk of hypertension measured over a longer period and across the full range of gestational ages. The authors conducted a national cohort study of all infants born in Sweden from 1973 through 1979 (n = 636,552), including 28,220 born preterm (<37 weeks), followed to ages 25.5-37.0 years to determine whether individuals born preterm were more likely to be prescribed antihypertensive medications in 2005-2009 than those born full term. Antihypertensive medication data were obtained from all outpatient and inpatient pharmacies throughout Sweden. Young adults who were born preterm had an increased relative rate of antihypertensive medication prescription that increased monotonically by earlier gestational age and that was independent of fetal growth. The adjusted odds ratio for ?1 antihypertensive medications/year ranged from 1.25 (95% confidence interval: 1.12, 1.39) for those born near term (35-36 weeks) to 2.51 (95% confidence interval: 1.11, 5.68) for those born extremely preterm (23-27 weeks) relative to those born full term. These findings suggest that preterm birth is strongly associated with hypertension in young adulthood, including an increased risk among those born near term.

Abstract

This nationwide Swedish study used geocoded data from all businesses in Sweden to examine the distribution of 12 main categories of goods, services, and resources in 6986 neighborhoods, categorized as low, moderate, and high neighborhood deprivation. The main findings were that high- and moderate-deprivation neighborhoods had a significantly higher prevalence of all types of goods, services, and resources than low-deprivation neighborhoods. These findings do not support previous research that hypothesizes that poorer health among people in deprived neighborhoods is explained by a lack of health-promoting resources, although a higher presence of health-damaging resources may play a role.

Abstract

Recent studies suggest an increased risk of adverse mental health outcomes among young adults who were born preterm. These studies have been based mainly on hospital data, thus missing large numbers of mental health problems that do not require inpatient treatment. We used national outpatient and inpatient pharmacy data to evaluate whether individuals who were born preterm were more likely to be prescribed psychiatric medications during young adulthood than individuals who were born full term.A national cohort of all infants born in Sweden from 1973 through 1979 [N?=?635,933, including 28,799 who were born preterm (<37 weeks)] was followed to ages 25.5-34.0 years to determine whether psychotropic medications (antidepressants, antipsychotics, anxiolytics, hypnotics/sedatives and/or psychostimulants) were prescribed in 2005-06.A trend of increasing rate of prescriptions for antipsychotics, antidepressants and hypnotics/sedatives in young adulthood was observed by earlier gestational age at birth. Young adults who were extremely preterm at birth (23-27 weeks) were 3.1 times more likely to be prescribed antipsychotics [95% confidence interval (CI) 1.66-5.93], 1.8 times more likely to be prescribed antidepressants (95% CI 1.26-2.64) and 1.8 times more likely to be prescribed hypnotics/sedatives (95% CI 1.15-2.96) than individuals who were full term at birth, after adjusting for potential confounders.This national cohort study, using outpatient and inpatient pharmacy data, suggests that preterm birth has important independent effects on mental health that extend at least into young adulthood.

Abstract

We assessed changes in cardiovascular disease-related health outcomes and risk factors among American Indians and Alaska Natives by age and gender.We used cross-sectional data from the 1995 to 1996 and the 2005 to 2006 Behavioral Risk Factor Surveillance System. The respondents were 2548 American Indian and Alaska Native women and men aged 18 years or older in 1995-1996 and 11 104 women and men in 2005-2006. We analyzed the prevalence of type 2 diabetes, obesity, hypertension, cigarette smoking, sedentary behavior, and low vegetable or fruit intake.From 1995-1996 to 2005-2006, the adjusted prevalence of diabetes among American Indians and Alaska Natives increased by 26.9%, from 6.7% to 8.5%, and obesity increased by 25.3%, from 24.9% to 31.2%. Hypertension increased by 5%, from 28.1% to 29.5%. Multiple logistic models showed no meaningful changes in smoking, sedentary behavior, or intake of fruits or vegetables. In 2005-2006, 79% of the population had 1 or more of the 6 risk factors, and 46% had 2 or more.Diabetes, obesity, and hypertension and their associated risk factors should be studied further among urban, rural, and reservation American Indian and Alaska Native populations, and effective primary and secondary prevention efforts are critical.

Predictors of Hypertension Awareness, Treatment, and Control Among Mexican American Women and MenJOURNAL OF GENERAL INTERNAL MEDICINEBersamin, A., Stafford, R. S., Winkleby, M. A.2009; 24: 521-527

Abstract

The burden of hypertension and related health care needs among Mexican Americans will likely increase substantially in the near future.In a nationally representative sample of U.S. Mexican American adults we examined: 1) the full range of blood pressure categories, from normal to severe; 2) predictors of hypertension awareness, treatment and control and; 3) prevalence of comorbidities among those with hypertension.Cross-sectional analysis of pooled data from the National Health and Nutrition Examination Surveys (NHANES), 1999-2004.The group of participants encompassed 1,359 Mexican American women and 1,421 Mexican American men, aged 25-84 years, who underwent a standardized physical examination.Physiologic measures of blood pressure, body mass index, and diabetes. Questionnaire assessment of blood pressure awareness and treatment.Prevalence of Stage 1 hypertension was low and similar between women and men ( approximately 10%). Among hypertensives, awareness and treatment were suboptimal, particularly among younger adults (65% unaware, 71% untreated) and those without health insurance (51% unaware, 62% untreated). Among treated hypertensives, control was suboptimal for 56%; of these, 23% had stage >/=2 hypertension. Clustering of CVD risk factors was common; among hypertensive adults, 51% of women and 55% of men were also overweight or obese; 24% of women and 23% of men had all three chronic conditions-hypertension, overweight/obesity and diabetes.Management of hypertension in Mexican American adults fails at multiple critical points along an optimal treatment pathway. Tailored strategies to improve hypertension awareness, treatment and control rates must be a public health priority.

Abstract

As part of a 5-year community-based intervention in Salinas, California, the Steps to a Healthier Salinas team developed a taqueria intervention addressing obesity and diabetes among Mexican Americans. The authors present: (a) a comparison of service/entrée options for Salinas taquerias (n = 35) and fast-food restaurants ( n = 38) at baseline, (b) a case study of one taqueria, (c) a description of a healthy nutrition tool kit tailored to taquerias, and (d) an evaluation of the intervention at Year 3. It was found that traditional Mexican American-style menu offerings at taquerias tended to be healthier than American-style fast-food restaurant offerings. In addition, the initial response to the intervention has shown positive changes, which include the taqueria owners promoting available healthy menu items and modifying other menu offerings to reduce fats and increase fruit and vegetable availability. This, in turn, has led to a transition of the owners' perceptions of themselves as gatekeepers for a healthy community.

Abstract

Signal detection analysis, a form of recursive partitioning, was used to identify combinations of sociodemographic and acculturation factors that predict trying to lose weight in a community-based sample of 957 overweight and obese Mexican-American adults (ages 18-69 years).Data were pooled from the 2004 and 2006 Behavioral Risk Factor Surveillance System conducted in a low-income, semi-rural community in California.Overall, 59 % of the population reported trying to lose weight. The proportion of adults who were trying to lose weight was highly variable across the seven mutually exclusive groups identified by signal detection (range 30-79 %). Significant predictors of trying to lose weight included BMI, gender, age and income. Women who were very overweight (BMI > 28.5 kg/m2) were most likely to be trying to lose weight (79 %), followed by very overweight higher-income men and moderately overweight (BMI = 25.0-28.5 kg/m2) higher-income women (72 % and 70 %, respectively). Moderately overweight men, aged 28-69 years, were the least likely to be trying to lose weight (30 %), followed by moderately overweight lower-income women (47 %) and very overweight lower-income men (49 %). The latter group is of particular concern since they have characteristics associated with medical complications of obesity (low education and poor access to medical care).Our findings highlight opportunities and challenges for public health professionals working with overweight Mexican-American adults - particularly lower-income adults who were born in Mexico - who are not trying to lose weight and are therefore at high risk for obesity-related co-morbidities.

Abstract

This paper examines trends in the neighbourhood food store environment (defined by the number and geographic density of food stores of each type in a neighbourhood), and in food consumption behaviour and overweight risk of 5779 men and women.The study used data gathered by the Stanford Heart Disease Prevention Program in four cross-sectional surveys conducted from 1981 to 1990.Four mid-sized cities in agricultural regions of California.In total, 3154 women and 2625 men, aged 25-74 years.From 1981 to 1990, there were large increases in the number and density of neighbourhood stores selling sweets, pizza stores, small grocery stores and fast-food restaurants. During this period, the percentage of women and men who adopted healthy food behaviours increased but so did the percentage who adopted less healthy food behaviours. The percentage who were obese increased by 28% in women and 24% in men.Findings point to increases in neighbourhood food stores that generally offer mostly unhealthy foods, and also to the importance of examining other food pattern changes that may have a substantial impact on obesity, such as large increases in portion sizes during the 1980s.

Abstract

Discrimination has been shown as a major causal factor in health disparities, yet little is known about the relationship between perceived medical discrimination (versus general discrimination outside of medical settings) and cancer screening behaviors. We examined whether perceived medical discrimination is associated with lower screening rates for colorectal and breast cancers among racial and ethnic minority adult Californians.Pooled cross-sectional data from 2003 and 2005 California Health Interview Survey were examined for cancer screening trends among African American, American Indian/Alaskan Native, Asian, and Latino adult respondents reporting perceived medical discrimination compared with those not reporting discrimination (n = 11,245). Outcome measures were dichotomous screening variables for colorectal cancer among respondents ages 50 to 75 years and breast cancer among women ages 40 to 75 years.Women perceiving medical discrimination were less likely to be screened for colorectal [odds ratio (OR), 0.66; 95% confidence interval (95% CI), 0.64-0.69] or breast cancer (OR, 0.52; 95% CI, 0.51-0.54) compared with women not perceiving discrimination. Although men who perceived medical discrimination were no less likely to be screened for colorectal cancer than those who did not (OR, 1.02; 95% CI, 0.97-1.07), significantly lower screening rates were found among men who perceived discrimination and reported having a usual source of health care (OR, 0.30; 95% CI, 0.28-0.32).These findings of a significant association between perceived racial or ethnic-based medical discrimination and cancer screening behaviors have serious implications for cancer health disparities. Gender differences in patterns for screening and perceived medical discrimination warrant further investigation.

Evaluation of risk factors and a community intervention to increase control and treatment of asthma in a low-income semi-rural California communityJOURNAL OF ASTHMAVogt, R., Bersamin, A., Ellemberg, C., Winkleby, M. A.2008; 45 (7): 568-574

Abstract

To better understand risk factors associated with current asthma in a low-income, ethnically diverse population, we analyzed pooled data from the 2004-2006 Behavioral Risk Factor Surveillance System survey conducted in Salinas, CA. We were particularly interested in modifiable risk factors, as the survey was conducted as part of a large community-based intervention that addresses asthma, obesity, and diabetes. We also conducted semi-structured interviews with key informants involved with the clinical, school, and community aspects of the intervention to inform the intervention's progress, and adapt practices and programs to reach those most in need. Of the 4925 adults in this analysis, 51% were Mexican-American and 32% lacked a high-school diploma; 227 women and 84 men had current asthma, and 194 were parents of children with current asthma; prevalences of 7.7%, 4.3%, and 7.0% respectively. Over 20% of women and men with asthma were current smokers and/or exposed to passive smoking, more than 50% reported less than the recommended 60 minutes or more of physical activity per day, and approximately 40% were obese or morbidly obese (42% of women and 36% of men compared to 26% of adults without asthma). Two of the strongest modifiable risk factors associated with current asthma and identified by the stepwise multiple regression models were: could not afford prescription medication(s) in the past 12 months (OR 2.5, p < 0.001 for adults with asthma, OR 1.8, p < 0.01 for parents of children with asthma) and morbid obesity (OR 3.4, p < 0.001 for adults with asthma). Among adults who reported one or more episodes of asthma in the past 30 days, 28% of women and 30% of men had not used a preventive medication, and 48% of women and 57% of men had not used a prescription asthma inhaler (20% had not used either). This study adds to the scarce body of literature on the prevalence of asthma and related risk factors in a predominately Mexican-American, semi-rural community, and illustrates how survey and key informant data can enhance knowledge of local study populations and guide interventions to improve asthma control and treatment.

Abstract

To investigate women's perceptions of neighborhood resources and hazards associated with poor diet, physical inactivity, and cigarette smoking.After interviewing city officials and analyzing visual assessments, three economically distinct neighborhoods in a mid-sized city were selected.Salinas, California, a predominantly Latino city.Eight fobcus groups, conducted in Spanish or English in the three neighborhoods. Thematic coding of focus group transcripts identified key concepts. Women also mapped their perceived neighborhood boundaries. Participants. Women who had at least one child under age 18 living with them.Women identified food stores, parks, recreation areas, and schools as key resources in their neighborhoods. They identified fast food restaurants, convenience stores, violent crime, gangs, and drug-associated issues as "hazards". Distinctions between resources and hazards were not always clear cut. For example, parks were sometimes considered dangerous, and fast food restaurants were sometimes considered a convenient and inexpensive way to feed one's family. Women's perceptions of their neighborhood boundaries differed greatly by type of neighborhood-the perceived neighborhood area (in acres) drawn by women in the lower-income neighborhood was one-fourth the size of the area drawn by women in the higher-income neighborhood.This qualitative, exploratory study illustrates how resources and hazards in one's neighborhood cannot be viewed as having solely one dimension-each may influence health behaviors both positively and negatively.

Abstract

Residence in a deprived neighbourhood is associated with lower rates of physical activity. Little is known about the manifestation of deprivation that mediates this relationship. This study aimed to investigate whether access to physical activity resources mediated the relationship between neighbourhood socioeconomic status and physical activity among women.Individual data from women participating in the Stanford Heart Disease Prevention Program (1979-90) were linked to census and archival data from existing records. Multilevel regression models were examined for energy expenditure and moderate and vigorous physical activity as reported in physical activity recalls.After accounting for individual-level socioeconomic status, women who lived in lower-socioeconomic status neighbourhoods reported greater energy expenditure, but undertook less moderate physical activity, than women in moderate-socioeconomic status neighbourhoods. In contrast, women living in higher-socioeconomic status neighbourhoods reported more vigorous physical activity than women in moderate-socioeconomic status neighbourhoods. Although availability of physical activity resources did not appear to mediate any neighbourhood socioeconomic status associations, several significant interactions emerged, suggesting that women with low income or who live in lower-socioeconomic status neighbourhoods may differentially benefit from greater physical activity resource availability.Although we found expected relationships between residence in a lower-socioeconomic status neighbourhood and undertaking less moderate or vigorous physical activity among women, we also found that these same women reported greater overall energy expenditure, perhaps as a result of greater work or travel demands. Greater availability of physical activity resources nearby appears to differentially benefit women living in lower-socioeconomic status neighbourhoods and low-income women, having implications for policy-making and planning.

Abstract

In 2003, the Monterey County Health Department, serving Salinas, California, was awarded one of 12 grants from the Steps to a HealthierUS Program to implement a 5-year, multiple-intervention community approach to reduce diabetes, asthma, and obesity. National adult and youth surveys to assess long-term outcomes are required by all Steps sites; however, site-specific surveys to assess intermediate outcomes are not required.Salinas is a medically underserved community of primarily Mexican American residents with high obesity rates and other poor health outcomes. The health department's Steps program has partnered with traditional organizations such as schools, senior centers, clinics, and faith-based organizations as well as novel organizations such as employers of agricultural workers and owners of taquerias.The health department and the Stanford Prevention Research Center developed new site-specific, community-focused partner surveys to assess intermediate outcomes to augment the nationally mandated surveys. These site-specific surveys will evaluate changes in organizational practices, policies, or both following the socioecological model, specifically the Spectrum of Prevention.Our site-specific partner surveys helped to 1) identify promising new partners, select initial partners from neighborhoods with the greatest financial need, and identify potentially successful community approaches; and 2) provide data for evaluating intermediate outcomes matched to national long-term outcomes so that policy and organizational level changes could be assessed. These quantitative surveys also provide important context-specific qualitative data, identifying opportunities for strengthening community partnerships.Developing site-specific partner surveys in multisite intervention studies can provide important data to guide local program efforts and assess progress toward intermediate outcomes matched to long-term outcomes from nationally mandated surveys.

Abstract

To determine whether socioeconomic and food-related physical characteristics of the neighbourhood are associated with body mass index (BMI; kg/m(2)) independently of individual-level sociodemographic and behavioural characteristics. Design andObservational study using (1) individual-level data previously gathered in five cross-sectional surveys conducted by the Stanford Heart Disease Prevention Program between 1979 and 1990 and (2) neighbourhood-level data from (a) the census to describe socioeconomic characteristics and (b) data obtained from government and commercial sources to describe exposure to different types of retail food stores as measured by store proximity, and count of stores per square mile. Data were analysed using multilevel modelling procedures. The setting was 82 neighbourhoods in agricultural regions of California.7595 adults, aged 25-74 years.After adjusting for age, gender, ethnicity, individual-level socioeconomic status, smoking, physical activity and nutrition knowledge, it was found that (1) adults who lived in low socioeconomic neighbourhoods had a higher mean BMI than adults who lived in high socioeconomic neighbourhoods; (2) higher neighbourhood density of small grocery stores was associated with higher BMI among women; and (3) closer proximity to chain supermarkets was associated with higher BMI among women.Living in low socioeconomic neighbourhoods, and in environments where healthy food is not readily available, is found to be associated with increased obesity risk. Unlike other studies which examined populations in other parts of the US, a positive association between living close to supermarkets and reduced obesity risk was not found in this study. A better understanding of the mechanisms by which neighbourhood physical characteristics influence obesity risk is needed.

Abstract

Carotid endarterectomy (CEA) has been shown to decrease future ischemic stroke risk in selected patients. However, clinical trials did not examine the risk-benefit ratio for nonwhites, who have a greater ischemic stroke risk than whites. In general, few studies have examined the effects of race on CEA use and complications, and data on race and CEA readmission are lacking.This study used administrative data for patients discharged from California hospitals between January 1 and December 31, 2000. Selection criteria of cases included: ICD-9 principal procedure code 38.12, principal diagnostic code 433 and diagnosis-related group 5. There were 8,080 white and 1196 nonwhite patients (228 blacks, 643 Hispanics, 325 Asians/Pacific Islanders) identified that underwent an elective and isolated CEA. For both groups, CEA rates were compared. Logistic regression was used to examine the independent effects of race on in-hospital death and stroke, as well as CEA readmission.Rates of CEA use were more than three times greater for whites than nonwhites, although nonwhites were more likely to have symptomatic disease. For all patients, the complication rate was 1.9%. However, the odds of in-hospital death and stroke were greater for nonwhites than whites, but after adjustment for patient and hospital factors, these differences were only significant for stroke (OR = 1.7, P = 0.013). For both outcomes, the final models had good predictive accuracy. Overall, CEA readmission risk was 7%, and no significant racial differences were observed (P = 0.110).The data suggest that CEA is performed safely in California. However, nonwhites had lower rates of initial CEA use but higher rates of in-hospital death and stroke than whites. Racial differences in stroke risk persisted after adjustment for patient and hospital factors. Finally, this study found that despite significant racial disparities in initial CEA use, whites and nonwhites were similar in their CEA readmission rates. These findings may suggest that screening initiatives are lacking for nonwhites, which may increase their risk for poorer outcomes.

The Stanford Medical Youth Science Program: 18 years of a biomedical program for low-income high school studentsACADEMIC MEDICINEWinkleby, M. A.2007; 82 (2): 139-145

Abstract

The Stanford Medical Youth Science Program (SMYSP) is a biomedical pipeline program that seeks to diversify the health professions by providing academic enrichment in the medical sciences and college admissions support to very low-income high school students. Each summer 24 students are recruited from over 250 California high schools for the five-week residential program, led by 10 undergraduate students. Participants divide their time between classroom instruction, anatomy practicums, hospital field placements, research projects, and college admissions advising. Since its inception in 1988, 405 students have completed SMYSP and 96% have been observed for up to 18 years. The majority are from underrepresented minority groups (33.3% Latino, 21.7% African American, 4.0% Native American), many with poor academic preparation. One hundred percent of age-eligible participants have graduated from high school, and 99% have been admitted to college. Of those admitted to college (and not currently college students), 81% have earned a four-year college degree, the majority majoring in biological and physical sciences (57.1%). Among four-year college graduates, 52% are attending or have graduated from medical or graduate school. Many of the four-year college graduates (44.4%) are becoming or have become health professionals. This program, distinguished by direct participation in the sciences, strong mentoring, college admissions preparation, and long-term career guidance, has been highly successful in reaching low-income students and preparing them for medical and other careers. Results highlight the need to track students for as long as 10 to 15 years to accurately assess college graduation rates and acceptance to medical and graduate school.

Abstract

We examined whether the influence of neighborhood-level socioeconomic status (SES) on mortality differed by individual-level SES.We used a population-based, mortality follow-up study of 4476 women and 3721 men, who were predominately non-HIspanic White and aged 25-74 years at baseline, from 82 neighborhoods in 4 California cities. Participants were surveyed between 1979 and 1990, and were followed until December 31, 2002 (1148 deaths; mean follow-up time 17.4 years). Neighborhood SES was defined by 5 census variables and was divided into 3 levels. Individual SES was defined by a composite of educational level and household income and was divided into tertiles.Death rates among women of low SES were highest in high-SES neighborhoods (1907/100000 person-years), lower in moderate-SES neighborhoods (1323), and lowest in low-SES neighborhoods (1128). Similar to women, rates among men of low SES were 1928, 1646, and 1590 in high-, moderate-, and low-SES neighborhoods, respectively. Differences were not explained by individual-level baseline risk factors.The disparities in mortality by neighborhood of residence among women and men of low SES demonstrate that they do not benefit from the higher quality of resources and knowledge generally associated with neighborhoods that have higher SES.

Abstract

A number of studies have established links between neighborhood social environments and health. In a previous study of 8197 adults, death rates for adults with low socioeconomic status (SES) were highest in high-SES neighborhoods, lower in moderate-SES neighborhoods and lowest in low-SES neighborhoods. This study examines whether these findings extend to time to hospitalization.Population-based study of 1686 women and men, aged 25 to 74 at baseline, from 82 neighborhoods in four California cities. Participants were surveyed and medically examined in 1989-1990 and followed through the end of 2002. Neighborhood-level SES was defined by five census variables and divided into three levels. Individual-level SES was defined by household income and educational level and divided into tertiles (nine individual/neighborhood SES groups).There were 627 hospitalizations. The age- and gender-adjusted rates of any hospitalization between 1989-1990 and the end of 2002 for adults with low SES were highest for those living in high-SES neighborhoods (51% compared with 28% to 38% for adults from the other eight individual/neighborhood groups). For these adults, time to hospitalization, as indicated by survival curves, was significantly shorter compared with the other individual/neighborhood groups (p < 0.01, multilevel Cox proportional hazards model). Findings were not explained by baseline differences in individual-level sociodemographic characteristics, health behaviors or risk factors, health status, or proximity to neighborhood goods and services.These findings suggest that factors leading to increased mortality for adults with low SES in high-SES neighborhoods also affect hospitalization.

Abstract

To determine whether neighborhood-level deprivation is independently associated with cardiovascular disease (CVD) health behaviors/risk factors in the Swedish population.Pooled cross-sectional data, Swedish Annual Level of Living Survey (1996-2000) linked with indicators of neighborhood-level (i.e. Small Area Market Statistics areas) deprivation (1997), to examine the association between neighborhood-level deprivation and individual-level smoking, physical inactivity, obesity, diabetes, and hypertension among women and men, aged 25-64 (n = 18,081). Data were analyzed with a series of logistic regression models that adjusted for individual-level age, gender, marital status, immigration status, urbanization, and a comprehensive measure of socioeconomic status (SES). Interactions were tested to determine whether neighborhood effects varied by SES or length of neighborhood exposure.Living in a neighborhood with low deprivation was protective (i.e. lower odds) for smoking, while living in a neighborhood with high deprivation was harmful (i.e. higher odds) for smoking, physical inactivity, and obesity (compared with living in a neighborhood with moderate deprivation). These associations were significant after adjustment for individual-level characteristics. There was no evidence that the neighborhood deprivation associations varied by individual-level SES or length of neighborhood exposure.Neighborhood-level deprivation exerted important protective and harmful associations with health behaviors/risk factors related to CVD. The significance to public health is substantial because of the number of persons at risk as well as the serious health consequences of CVD. These results suggest that interventions focusing on changing contextual aspects of neighborhoods, in addition to changing individual behaviors, may have a greater impact on CVD than a sole focus on individuals.

Abstract

With the rapidly increasing prevalence of obesity in the United States, and the minimal success of education-based interventions, there is growing interest in understanding the role of the neighborhood food environment in determining dietary behavior. This study, as part of a larger study, identifies historical data on retail food stores, evaluates strengths and limitations of the data for research, and assesses the comparability of historical retail food store data from a government and a commercial source. Five government and commercial listings of retail food stores were identified. The California State Board of Equalization (SBOE) database was selected and then compared to telephone business directory listings. The Spearman's correlation coefficient was used to assess the congruency of food store counts per census tract between the SBOE and telephone business directory databases. The setting was four cities in Northern California, 1979-1990. The SBOE and telephone business directory databases listed 127 and 351 retail food stores, respectively. The SBOE listed 36 stores not listed by the telephone business directories, while the telephone business directories listed 260 stores not listed by the SBOE. Spearman's correlation coefficients between estimates of stores per census tract made from the SBOE listings and those made from the telephone business directory listings were approximately 0.5 (p < .0001) for the types of stores studied (chain supermarkets, small grocery stores, and chain convenience markets). We conclude that, depending on the specific aims of the study, caution and considerable effort must be exercised in using and applying historical data on retail food stores.

Abstract

The authors examined associations between neighborhood-level deprivation and cardiovascular disease-related health knowledge and behavior changes, as well as the estimated 12-year probability of experiencing a coronary heart disease event. Primary analyses included multilevel regression models among 8,197 women and men living in 82 neighborhoods in four northern California cities who were interviewed in one of five surveys conducted between 1979 and 1990. After controlling for age, gender, marital status, race/ethnicity, city, and time, the authors found that adults living in high-deprivation neighborhoods had significantly lower health knowledge and a higher probability of no positive behavior changes than did adults in moderately deprived neighborhoods (i.e., harmful effects). Conversely, those living in low-deprivation neighborhoods had significantly higher health knowledge and lower probabilities of no positive behavior changes and estimated risk of coronary heart disease (i.e., protective effects). The association between high neighborhood deprivation and no positive behavior changes remained statistically significant after additional adjustment for a composite measure of individual-level socioeconomic status. Associations with neighborhood deprivation did not vary by individual-level socioeconomic status. These results suggest that focusing exclusively on changing individuals' behaviors will have a limited effect unless contextual influences at the neighborhood level are also addressed.

Abstract

Previous studies suggest that the physical availability of alcohol may mediate the association between neighbourhood-level material deprivation and alcohol consumption. This study tests the relationships between neighbourhood-level deprivation, alcohol availability, and individual-level alcohol consumption using a multilevel analysis.Data are from cross-sectional surveys conducted between 1979 and 1990 as part of the Stanford Heart Disease Prevention Program (SHDPP). Women and men (n = 8197) living in four northern/central California cities and 82 neighbourhoods were linked to neighbourhood deprivation variables derived from the US census (e.g. unemployment, crowded housing) and to measures of alcohol availability (density of outlets in the respondent's neighbourhood, nearest distance to an outlet from the respondent's home, and number of outlets within a half mile radius of the respondent's home). Separate analyses were conducted for on- and off-sale outlets.The most deprived neighbourhoods had substantially higher levels of alcohol outlet density than the least deprived neighbourhoods (45.5% vs 14.8%, respectively). However, multilevel analyses showed that the least deprived neighbourhoods were associated with the heaviest alcohol consumption, even after adjusting for individual-level sociodemographic characteristics (OR 1.30, CI 1.08-1.56). Alcohol availability was not associated with heavy drinking and thus did not mediate the relationship between neighbourhood deprivation and heavy alcohol consumption.Although alcohol availability is concentrated in the most deprived neighbourhoods, women and men in least deprived neighbourhoods are most likely to be heavy drinkers. This mismatch between supply and demand may cause people in the most deprived neighbourhoods to disproportionately suffer the negative health consequences of living near alcohol outlets.

Abstract

To assess the effects of neighbourhood level socioeconomic status (SES) and convenience store concentration on individual level smoking, after consideration of individual level characteristics.Individual sociodemographic characteristics and smoking were obtained from five cross sectional surveys (1979-1990). Participants' addresses were geocoded and linked with census data for measuring neighbourhood SES and with telephone yellow page listings for measuring convenience store concentration (density in a neighbourhood, distance between a participant's home and the nearest convenience store, and number of convenience stores within a one mile radius of a participant's home). The data were analysed with multilevel Poisson regression models.82 neighbourhoods in four northern California cities.8121 women and men aged 25-74 from the Stanford heart disease prevention programme.Lower neighbourhood SES and higher convenience store concentration, measured by density and distance, were both significantly associated with higher level of individual smoking after taking individual characteristics into account. The association between convenience store density and individual smoking was modified by individual SES and neighbourhood SES.These findings are consistent with a growing body of literature suggesting that the socioeconomic and physical environments of neighbourhoods are associated with individual level smoking.

Abstract

U.S. Latino adults have experienced an 80% increase in obesity in the last decade.A cross-sectional survey of 18-64-year-old Latino women (N = 380) and men (N = 335) from a community sample, and men (N = 186) from an agricultural labor camp sample in Monterey County, California, provided data on correlates of obesity.In the community and labor camp samples, prevalences of chronic disease risk factors (high blood pressure and cholesterol, diabetes) were 1.5-7 times higher in the heaviest compared with the leanest weight groups. Higher acculturation (generational status, years lived in the United States) was the strongest correlate of obesity (measured by BMI) in the community sample (P < 0.001), followed by less exercise and poorer diet (P values < 0.05). Women who exercised <2.5 h/week, watched TV regularly, ate chips/fried snacks, and ate no fruit the previous day were 45 lbs heavier than women with healthier habits. Men who did not exercise, rarely trimmed fat from meat, and ate fried foods the previous day were 16 lbs heavier than men with healthier habits. Discussions with health care providers about diet/exercise were associated with more accurate weight perception and more weight loss attempts in obese participants in both samples.The associations of acculturation, exercise, and diet to BMI implicate societal as well as individual contributors to obesity among U.S. Latinos.

Abstract

Assess changes in chronic disease-related health behaviors and risk factors from 1990 to 2000, by race/ethnicity, age, and gender.Stratified cross-sectional design.United States.16,948 black, 11,956 Hispanic, and 158,707 white women and men, ages 18 to 74.Cigarette smoking, obesity, sedentary behavior, low vegetable or fruit intake. From the Behavioral Risk Factor Surveillance System.Young women and men, ages 18 to 24, had poor health profiles and experienced adverse changes from 1990 to 2000. After the variables were adjusted for education and income, these young people had the highest prevalence of smoking (34%-36% current smokers among white women and men), the largest increases in smoking (10%-12% increase among white women and men; 9% increase among Hispanic women), and large increases in obesity (4%-9% increase, all gender and racial/ethnic groups). Young women and men from each racial/ethnic group also had high levels of sedentary behavior (approximately 20%-30%) and low vegetable or fruit intake (approximately 35%-50%). In contrast, older Hispanic women and men and older black men, ages 65 to 74, showed some of the most positive changes. They had the largest decreases in smoking (Hispanic women), largest decreases in sedentary behavior (Hispanic women and black men), and largest increases in vegetable or fruit intake (Hispanic women and men, and black men).The poor and worsening health profile of young women and men is a particular concern, as they will soon enter the ages of high chronic disease burden.

Abstract

In this study, the authors examined whether neighborhood socioeconomic environment predicted incident coronary heart disease after adjustment for individual-level characteristics. A random sample of the Swedish population (25,319 women and men aged 35-74 years) was interviewed between 1986 and 1993 and was followed through December 1997 for incident coronary heart disease (1,189 events). Neighborhood socioeconomic environment was defined by small-area market statistics (6,145 neighborhoods) and measured by two indicators: neighborhood education (proportion of people with less than 10 years of education in the neighborhood) and neighborhood income (proportion of people with incomes in the lowest national income quartile). Separate multilevel Cox proportional hazards models showed that low neighborhood education and low neighborhood income each predicted incident coronary heart disease after adjustment for age, sex, and individual-level education and income (hazard ratios were 1.25 and 1.23, respectively). The authors conclude that neighborhood socioeconomic environment predicts incident coronary heart disease, having a significant effect on coronary heart disease risk beyond the individual effect.

Abstract

To test whether high school students' participation in advocacy activities related to the advertising, availability, and use of tobacco in their communities would prevent or reduce their own tobacco use.Ten continuation high schools in northern California, randomly assigned to a semester-long program in which students either carried out advocacy activities to counter environmental-level smoking influences in their communities (treatment) or learned about drug and alcohol abuse prevention (control).Eleventh and 12th grade high school students; 5 (advocacy) treatment and 5 control schools over 4 semesters from 2000 through 2002.Self-reported smoking defined as nonsmokers (those who had never smoked tobacco or those who were former smokers), light smokers (those who smoked <1 pack per week), or regular smokers (those who smoked >or=1 pack per week), and confirmed by carbon monoxide level readings. The following 3 constructs related to social cognitive theory- perceived incentive value, perceived self-efficacy, and outcome expectancies-were assessed.There was a significant net change from baseline to the end of the semester (after the intervention) between treatment and control schools for students who were regular smokers, but not for students who were nonsmokers or light smokers. Regular smoking decreased 3.8% in treatment schools and increased 1.5% in control schools (P

Abstract

To examine whether cancer-related health behaviors and screening practices differ within a population of Latino adults, including those often missed by cancer surveys.Cross-sectional survey, conducted in 2000. Sample of 461 women and 356 men from the community (75% with unlisted telephones) and 188 men from agricultural labor camps, 18-64 years of age.Monterey County, California.Six health behaviors and risk factors: obesity, poor nutrition, physical inactivity, high alcohol use, and smoking. Five health practices and screening tests used to detect cervical, breast, and colorectal cancer.Most respondents were born in Mexico, spoke Spanish, and had lived in the United States 10 years or more. In both surveys, more than 60% were overweight including more than 20% who were obese. Men, especially from labor camps, reported high dietary fat intake, low fruit intake, and high alcohol use. For every additional 5 years lived in the United States, the odds of obesity increased 25% for women, and the odds of high-fat/fast food intake and high alcohol use increased 35% and 50%, respectively for labor camp men. Screening rates for cervical and breast cancer were high and met Healthy People 2000 objectives. In contrast, screening rates for colorectal cancer were low; among those 50 and older, approximately 70%-80% of women and men from the community sample and 100% of men from the labor camp sample had never had a blood stool test. Unmarried women, in particular, had poor nutrition and low screening rates.Cancer control programs for Latinos need a particular focus on weight, nutrition, physical activity, alcohol, and colorectal screening.

African American women and men at high and low risk for hypertension: A signal detection analysis of NHANES III, 1988-19941PREVENTIVE MEDICINECollins, R., Winkleby, M. A.2002; 35 (4): 303-312

Abstract

African Americans have some of the highest rates of hypertension in the world. This study identified subgroups of U.S. African American women and men with particularly high and low rates of hypertension.Data are presented for 1,911 Black women and 1,657 Black men, ages 25-84 from the Third National Health and Nutrition Examination Survey, 1988-1994. Signal detection methodology identified high and low risk subgroups; stratified analyses characterized the population of hypertensives.We identified 12 distinct subgroups with highly variable rates of hypertension (11-78%). The two groups with the highest rates of hypertension (>70% hypertensive) were more likely to be middle aged or older, less educated, overweight or obese (>80%), physically inactive (50%), and to have diabetes (28 and 100% diabetic). The two groups with the lowest hypertension rates (<18% hypertensive) were more likely to be younger, but were also overweight or obese (>50%). Among hypertensives, those who were uncontrolled and not on antihypertensive medications were distinguished by their male gender, younger age, and infrequent contact with a physician.Hypertension rates vary substantially within African Americans, illustrating the need for effective weight management, diabetes control, and increased access to health care for those at highest risk.

Abstract

Cervical cancer is a major health problem in Mexico. The national mortality rate due to cervical cancer was estimated at 21.8 per 100,000 among women over 15 years of age in 1994. Reasons for this high prevalence have not been defined, although it may be influenced by lack of access to health care, lack of knowledge about the Pap procedure, or cultural beliefs. While some studies have examined barriers to Pap screening, most have focused on urban samples. We conducted a pilot study using direct interviews to learn about factors that may influence cervical cancer screening among rural Mexican women. We interviewed 97 rural women between the ages of 16 and 66 and found that 52% had not received a Pap smear within the last 2 years (of that group, 62% had never received a Pap smear). In our sample, the most frequent reason for not obtaining a Pap smear was anxiety regarding physical privacy (50%). Less frequent reasons were lack of knowledge (18%) and difficulty accessing health care (14%). Women who had delivered children were significantly more likely to have received a Pap smear (71%) than women who had no children (10%), P < 0.05. The responses of many women suggest that compliance with cervical cancer screening would be enhanced by addressing cultural beliefs, encouraging conversations about women's health issues, and increasing the number of female health care providers.

Identification of population subgroups of children and adolescents with high asthma prevalence - Findings from the Third National Health and Nutrition Examination SurveyARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINERodriguez, M. A., Winkleby, M. A., Ahn, D., Sundquist, J., Kraemer, H. C.2002; 156 (3): 269-275

Abstract

To provide national estimates of asthma prevalence in African-American, Mexican American and white (non-Latino) children and adolescents using several common definitions; to evaluate familial, sociodemographic, and environmental risk factors that are independently associated with current asthma in children; and to identify subgroups at particular risk for current asthma using 2 complementary data analytic approaches.Cross-sectional study, using the Third National Health and Nutrition Examination Survey, 1988-1994.Eighty-nine mobile examination centers in the United States.Twelve thousand three hundred eighty-eight African American, Mexican American, and white (non-Latino) children and adolescents, aged 2 months through 16 years, selected from a systematic random, population-based, nationally representative sample.Current asthma, defined by caregivers who reported that their child currently had doctor-diagnosed asthma.The overall prevalence of current asthma was 6.7% (95% confidence interval [CI], 5.6-7.8). Odds ratios for current asthma from the multiple regression analysis were 4.00 (95% CI, 2.90-5.52) for children with a parental history of asthma or hay fever, 1.94 (95% CI, 1.09-3.46) for children with body mass index (calculated as weight in kilograms divided by the square of height in meters) greater than or equal to the 85th percentile, and 1.64 (95% CI, 1.20-2.26) for children of African American ethnicity. African American and Mexican American children showed a consistent prevalence of current asthma across age while white children showed an increase in prevalence with age. The 2 highest-risk subgroups identified by the signal detection analysis were composed of children with a parental history of asthma or hay fever who were 10 years or older with a body mass index greater than or equal to the 85th percentile (31.0% current asthma), and children with a parental history who were 10 years or younger and of African American ethnicity (15.6% current asthma).The findings from this analysis show a strong independent association between obesity and current asthma in children and adolescents, and confirm previous reports of a parental history of asthma or hay fever and African American ethnicity as additional important risk factors.

Abstract

This study identified mutually exclusive groups of men at high and low risk for use of chewing tobacco and for quitting.Analyses used a national sample of 1340 non-Hispanic Black, 1358 Mexican American, and 1673 non-Hispanic White men, aged 25 to 64, who participated in the National Health and Nutrition Examination Survey III from 1988 to 1994. Signal detection analysis was used to delineate high- and low-risk subgroups; survival analysis was used to estimate hazard curves for comparing age at onset for chewing tobacco use with that for smoking.Rural, lower-income Black and White men had the highest regular use of chewing tobacco (33.3%), followed by rural, higher-income men regardless of race/ethnicity (14.9%). Southern men who began using chewing tobacco during adulthood had the lowest quit rate (22.5%). In sharp contrast to smoking, chewing tobacco showed a continued onset throughout adulthood.Because subgroups of men show highly different chewing tobacco use and quit rates and because age at chewing tobacco onset occurs across the life span, prevention and cessation programs should be specific to different risk groups and distinct from smoking programs.

Abstract

This paper investigates whether neighborhood material deprivation is associated with cardiovascular disease (CVD) risk factors (physical inactivity, diabetes, smoking, body mass index, blood pressure, cholesterol) independent of individual socioeconomic status (SES) in Black, Mexican-American, and White women and men aged 25-64 using data from the Third National Health and Nutrition Examination Survey (1988-1994, N = 9,961). The data were linked to 1990 Census tract characteristics (unemployment, car ownership, rented housing, crowded housing), which were used to construct a neighborhood-level material deprivation index. Results are stratified by gender and race/ethnicity. Multiple logistic and linear regression models were specified using SUDAAN to account for the clustered design. In general, residence in a deprived neighborhood increased the probability of having an adverse CVD risk profile, independent of an individual's SES. For example, after adjusting for SES, Black women living in deprived neighborhoods were at increased risk of being diabetic, being a smoker, and having a higher body mass index and blood pressure compared to Black women living in less deprived neighborhoods (P values

Abstract

Approximately 10.2 million persons in the United States sometimes or often do not have enough food to eat, a condition known as food insufficiency. Using cross-sectional data from the Third National Health and Nutrition Examination Survey (NHANES III), we examined whether dietary intakes and serum nutrients differed between adults from food-insufficient families (FIF) and adults from food-sufficient families (FSF). Results from analyses, stratified by age group and adjusted for family income and other important covariates, revealed several significant findings (P < 0.05). Compared with their food-sufficient counterparts, younger adults (aged 20-59 y) from FIF had lower intakes of calcium and were more likely to have calcium and vitamin E intakes below 50% of the recommended amounts on a given day. Younger adults from FIF also reported lower 1-mo frequency of consumption of milk/milk products, fruits/fruit juices and vegetables. In addition, younger adults from FIF had lower serum concentrations of total cholesterol, vitamin A and three carotenoids (alpha-carotene, beta-cryptoxanthin and lutein/zeaxanthin). Older adults (aged > or =60 y) from FIF had lower intakes of energy, vitamin B-6, magnesium, iron and zinc and were more likely to have iron and zinc intakes below 50% of the recommended amount on a given day. Older adults from FIF also had lower serum concentrations of high-density lipoprotein cholesterol, albumin, vitamin A, beta-cryptoxanthin and vitamin E. Both younger and older adults from FIF were more likely to have very low serum albumin (<35 g/L) than were adults from FSF. Our findings show that adults from FIF have diets that may compromise their health.

Abstract

Identifying subgroups of high-risk individuals can lead to the development of tailored interventions for those subgroups. This study compared two multivariate statistical methods (logistic regression and signal detection) and evaluated their ability to identify subgroups at risk. The methods identified similar risk predictors and had similar predictive accuracy in exploratory and validation samples. However, the 2 methods did not classify individuals into the same subgroups. Within subgroups, logistic regression identified individuals that were homogeneous in outcome but heterogeneous in risk predictors. In contrast, signal detection identified individuals that were homogeneous in both outcome and risk predictors. Because of the ability to identify homogeneous subgroups, signal detection may be more useful than logistic regression for designing distinct tailored interventions for subgroups of high-risk individuals.

Abstract

There are few studies of ethnic differences in cardiovascular disease (CVD) risk factors in older populations.To examine the association of ethnicity on CVD risk factors, after accounting for socioeconomic status (SES), and to examine health behaviors among those with CVD risk factors.Third National Health and Nutrition Examination Survey, 1988-1994.Eighty-nine mobile examination centers.700 black, 628 Mexican-American, and 2192 white women and men age 65 to 84 years.Ethnicity in relation to type II diabetes mellitus, physical inactivity, abdominal obesity, hypertension, cigarette smoking and non-high-density lipoprotein cholesterol (non-HDL-C).After accounting for age and SES, both black and Mexican-American women had significantly higher prevalences of type II diabetes than white women. In addition, black women were significantly more likely to have abdominal obesity and hypertension and to be physically inactive than white women. Black men had significantly higher prevalences of hypertension and physical inactivity than white men. However, black men had lower prevalences of abdominal obesity than white men, and black women had lower prevalences of high non-HDL-C than white women. Among those with CVD risk factors, health behaviors were in need of improvement, especially among Mexican-American women whose primary language was Spanish.In this national sample of older women and men, black and Mexican American women and black men were at the greatest risk for CVD. These findings parallel the heightened risk of CVD among younger ethnic minority populations and argue for appropriate primary and secondary prevention programs, modified for the language, cultural, and medical needs of older ethnic minorities.

Abstract

Although low-income women have higher rates of cardiovascular disease (CVD) than higher-income women, health promotion and disease prevention are often low priorities due to financial, family, and health care constraints. In addition, most low-income women live in environments that tend to support and even promote high risk CVD behaviors. Low-income African-American, Hispanic, and White women constitute one of the largest groups at high risk for CVD but few heart disease prevention programs have effectively reached them. The purpose of this project was to use feedback from focus groups to generate ideas about how to best structure and implement future CVD intervention programs tailored to low-income populations. Seven focus groups were conducted with 51 low-income African-American, Hispanic, and White women from two urban and two agricultural communities in California. The women in the study shared many common experiences and barriers to healthy lifestyles, despite their ethnic diversity. Results of the focus groups showed that women preferred heart disease prevention programs that would address multiple CVD risk factors, emphasize staying healthy for themselves, teach specific skills about how to adopt heart-healthy behaviors, and offer them choices in effecting behavioral change. For health information, they preferred visual formats to written formats. They also expressed a desire to develop knowledge to help them separate health "myths" from health "facts" in order to reduce their misconceptions about CVD. Finally, they stressed that health care policies and programs need to address social and financial barriers that impede the adoption of heart-healthy behaviors.

Differences in energy, nutrient, and food intakes in a US sample of Mexican-American women and men: Findings from the Third National Health and Nutrition Examination Survey, 1988-1994AMERICAN JOURNAL OF EPIDEMIOLOGYDixon, L. B., Sundquist, J., Winkleby, M.2000; 152 (6): 548-557

Abstract

As Mexican-American women and men migrate to the United States and/or become more acculturated, their diets may become less healthy, increasing their risk of cardiovascular disease. Data from the Third National Health and Nutrition Examination Survey (1988-1994) were used to compare whether energy, nutrient, and food intakes differed among three groups of Mexican-American women (n = 1,449) and men (n = 1,404) aged 25-64 years: those born in Mexico, those born in the United States whose primary language was Spanish, and those born in the United States whose primary language was English. Percentages of persons who met the national dietary guidelines for fat, fiber, and potassium and the recommended intakes of vitamins and minerals associated with cardiovascular disease were also compared. In general, Mexican Americans born in Mexico consumed significantly less fat and significantly more fiber; vitamins A, C, E, and B6; and folate, calcium, potassium, and magnesium than did those born in the United States, regardless of language spoken. More women and men born in Mexico met the dietary guidelines or recommended nutrient intakes than those born in the United States. The heart-healthy diets of women and men born in Mexico should be encouraged among all Mexican Americans living in the United States, especially given the increasing levels of obesity and diabetes among this rapidly growing group of Americans.

Abstract

The objective of this study was to provide population frequency distribution data for non-high-density lipoprotein (HDL) cholesterol (total cholesterol minus HDL cholesterol) concentrations and to evaluate whether differences exist by gender, ethnicity, or level of education. Serum levels of non-HDL cholesterol and sociodemographic characteristics were determined for 3,618 black, 3,528 Mexican-American, and 6,043 white women and men, aged >/=25 years, from a national cross-sectional survey of the US population (National Health And Nutrition Examination Survey III, 1988-1994). Age-adjusted non-HDL cholesterol concentrations were lower in women than men (154.1 vs 160.4 mg/dL, p <0.001). In women and men, age was positively associated with non-HDL cholesterol in the 25 to 64-year age range, and the slope of the association was steeper for women. For women and men >/=65 years, age was negatively associated with non-HDL cholesterol, and the slope of the association was steeper for men. Black women and men had lower non-HDL cholesterol levels than either Mexican-American or white women and men (women, p <0.02; men, p <0.001, for both ethnic contrasts). Women with less education had higher levels of non-HDL cholesterol than women with more education (p <0.01). These nationally representative population frequency distribution data provide non-HDL cholesterol reference levels for clinicians and investigators and indicate that there are significant variations in non-HDL cholesterol by gender, age, ethnicity, and level of education.

Abstract

The NHLBI (National Heart, Lung, and Blood Institute) Obesity Education Initiative Expert Panel recently proposed that clinicians and other health care professionals use a new treatment algorithm to identify patients for weight-loss treatment. In addition to the usual assessment of body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), the new algorithm includes the assessment of abdominal obesity (as measured by waist circumference) and other cardiovascular disease (CVD) risk factors.We examined the percentage of adults meeting the criteria of the panel's treatment algorithm: BMI > or =30 or ¿[BMI, 25.0-29.9 or waist circumference >88 cm (women) >102 cm (men)] and > or = 2 CVD risk factors¿ in a sample of 2844 black, 2754 Mexican American, and 3504 white adults, aged 25 to 64 years, from the Third National Health and Nutrition Examination Survey, 1988-1994.Across ethnic groups, more than 98% of adults (normal weight, overweight, and obese) received the same treatment recommendations using the panel's algorithm and an algorithm based only on BMI and CVD risk factors, without waist circumference. For normal-weight adults, almost none (0.0%-1.8%) had a large waist circumference as defined above and 2 or more CVD risk factors. Using the usual criterion of a BMI of 30 or higher, a substantial percentage of at-risk overweight women and men (BMI, 25.0-29.9) with 2 or more CVD risk factors were missed (8.4% and 19.3%, respectively).Despite the potential importance of abdominal obesity as a CVD risk factor, these results challenge the clinical utility of including waist circumference in this new algorithm and suggest that using BMI and CVD risk factors may be sufficient.

Country of birth, acculturation status and abdominal obesity in a national sample of Mexican-American women and menINTERNATIONAL JOURNAL OF EPIDEMIOLOGYSundquist, J., Winkleby, M.2000; 29 (3): 470-477

Abstract

Few studies have examined the influence of country of birth and acculturation status on indicators of obesity using national samples of Mexican-American women and men.We analysed data for 1387 Mexican-American women and 1404 Mexican- American men, ages 25-64, from the third National Health and Nutrition Examination Survey (1988-1994). We examined whether waist circumference and abdominal obesity varied by country of birth and acculturation status (primary language spoken), and whether among those with abdominal obesity, number of associated cardiovascular disease (CVD) risk factors varied by country of birth and acculturation status.Both country of birth and, to a lesser degree, acculturation status were significantly associated with waist circumference and abdominal obesity. Mexican-born women and men had the smallest waist circumference (90.4 cm, 94.0 cm respectively), US-born English-speaking women and men had intermediate waist circumference (93.6 cm, 97.3 cm), and US-born Spanish-speaking women and men had the largest waist circumference (96.9 cm, 97.7 cm), after accounting for age, education, per cent of energy from dietary fat, leisure-time physical activity, and smoking. All women had high prevalences of abdominal obesity, particularly US-born Spanish-speaking women (68.7%). In addition, US-born Spanish-speaking women with abdominal obesity were significantly more likely than their counterparts to have one or more of the following CVD risk factors: high serum insulin, non-insulin dependent diabetes, high blood lipids, and/or hypertension.These findings illustrate the heterogeneity of the Mexican-American population and suggest that country of birth and lack of acculturation to the majority culture, as well as secondary lifestyle changes, may explain the significant clinical differences observed in abdominal obesity within Mexican-American population subgroups.

Abstract

Focus groups were conducted with low-income African-American women in six different community settings in Northern California to assess their awareness of and concern for cardiovascular disease (CVD). These women had low awareness of the prevalence of CVD, attributed CVD to stress and low socioeconomic status, saw the media as an important source of health-related knowledge, and saw a need for more community awareness on CVD among African-American people.

Abstract

This study examined the extent to which cardiovascular disease risk factors differ among subgroups of Mexican Americans living in the United States.Using data from a national sample (1988-1994) of 1387 Mexican American women and 1404 Mexican American men, aged 25 to 64 years, we examined an estimate of coronary heart disease mortality risk and 5 primary cardiovascular disease risk factors: systolic blood pressure, body mass index, cigarette smoking, non-high-density lipoprotein cholesterol, and type 2 diabetes mellitus. Differences in risk were evaluated by country of birth and primary language spoken.Estimated 10-year coronary heart disease mortality risk per 1000 persons, adjusted for age and education, was highest for US-born Spanish-speaking men and women (27.5 and 11.4, respectively), intermediate for US-born English-speaking men and women (22.5 and 7.0), and lowest for Mexican-born men and women (20.0 and 6.6). A similar pattern of higher risk among US-born Spanish-speaking men and women was demonstrated for each of the 5 cardiovascular disease risk factors.These findings illustrate the heterogeneity of the Mexican American population and identify a new group at substantial risk for cardiovascular disease and in need of effective heart disease prevention programs.

Ethnic variation in cardiovascular disease risk factors among children and young adults - Findings from the Third National Health and Nutrition Examination Survey, 1988-1994JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATIONWinkleby, M. A., Robinson, T. N., Sundquist, J., Kraemer, H. C.1999; 281 (11): 1006-1013

Abstract

Knowledge about ethnic differences in cardiovascular disease (CVD) risk factors among children and young adults from national samples is limited.To evaluate ethnic differences in CVD risk factors, the age at which differences were first apparent, and whether differences remained after accounting for socioeconomic status (SES).Third National Health and Nutrition Examination Survey, 1988-1994.Eighty-nine mobile examination centers.A total of 2769 black, 2854 Mexican American, and 2063 white (non-Hispanic) children and young adults aged 6 to 24 years.Ethnicity and household level of education (SES) in relation to body mass index (BMI), percentage of energy from dietary fat, cigarette smoking, systolic blood pressure, glycosylated hemoglobin (HbA1c), and non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]).The BMI levels were significantly higher for black and Mexican American girls than for white girls, with ethnic differences evident by the age of 6 to 9 years (a difference of approximately 0.5 BMI units) and widening thereafter (a difference of >2 BMI units among 18- to 24-year-olds). Percentages of energy from dietary fat paralleled these findings and were also significantly higher for black than for white boys. Blood pressure levels were higher for black girls than for white girls in every age group, and glycosylated hemoglobin levels were highest for black and Mexican American girls and boys in every age group. In contrast, smoking prevalence was highest for white girls and boys, especially for those from low-SES homes (77% of young men and 61% of young women, aged 18-24 years, from low-SES homes were current smokers). All ethnic differences remained significant after accounting for SES and age.These findings show strong ethnic differences in CVD risk factors among youths of comparable age and SES from a large national sample. The differences highlight the need for heart disease prevention programs to begin early in childhood and continue throughout young adulthood to reduce the risk of atherosclerosis.

Abstract

In this article, we seek to confirm past studies that document increased levels of cardiovascular disease (CVD) risk factors among White men with lower educational attainment. Second, we include a population of Hispanic men (89% Mexican American) to examine the separate and interactive effects of ethnicity and education (our measure of socioeconomic status) on CVD risk factors. Third, we examine how education and ethnicity are related to receiving health messages from print media and interpersonal channels, with the hypothesis that less educated, higher CVD risk Hispanic and White men receive fewer messages than more educated men. Finally, we examine other psychosocial variables (e.g. knowledge, self-efficacy and motivation) that may help explain observed differences in CVD risk and health communication. The study sample included 2029 men, 25-64 years of age, from three population-based, cross-sectional surveys conducted from 1979 to 1990 as part of the Stanford Five-City Project. Hispanic and White men with lower educational attainment had higher levels of CVD risk factors, and received less health information from print media and interpersonal channels than Hispanic and White men with higher educational attainment. Furthermore, less educated men from both ethnic groups reported less CVD knowledge, lower self-efficacy and lower motivation to reduce CVD risk factors than higher educated men. These results highlight the need for effective intervention programs that target low educated Hispanic and White men to decrease their disproportionate risk of CVD.

Abstract

This paper identifies factors that predict achievement of a low-fat diet among 242 California adults with low literacy skills, following their participation in the Stanford Nutrition Action Program (SNAP), a randomized classroom-based nutrition intervention trial (1993-1994).The intervention classes received a newly developed curriculum that focuses on reducing dietary fat intake (SNAP); the control classes received an existing general nutrition (GN) curriculum. Data were collected at baseline and 3 months postintervention. This hypothesis-generating analysis uses a signal detection method to identify mutually exclusive groups that met the goal of a low fat diet, defined as < 30% of calories from total fat, at 3 months postintervention.Three mutually exclusive groups were identified. Twenty-three percent of Group 1, participants with high baseline dietary fat (> 60 g) who received either the GN or the SNAP curriculum, met the postintervention goal of < 30% of calories from total fat. Thirty-four percent of Group 2, participants with moderate baseline dietary fat (< or = 60 g) who received the GN curriculum, were successful. Sixty percent of Group 3, participants with moderate baseline dietary fat who received the SNAP curriculum, were successful. Members of Group 3 also significantly increased their intake of vegetables, grains, and fiber.Within this population of adults with low literacy skills, a large proportion of those with moderate baseline dietary fat who participated in the SNAP classes met the postintervention criteria for a low-fat diet. A much smaller proportion of those with high baseline dietary fat were successful, suggesting that this group may benefit from different, more intensive, or longer-term interventions.

Abstract

This article examines the effects of gender and socioeconomic factors on ethnic differences in body mass index (BMI) using a matched-pairs design of 688 pairs of Hispanics (principally Mexican American) and whites. Subjects, ages 25-74, were drawn from five population-based surveys conducted from 1979 to 1990 in four northern California cities.Hispanic women and men both had significantly higher BMI levels than the white women and men with whom they were matched (P < 0.001). These ethnic differences persisted across every level of education for both women and men, with the magnitude of the difference ranging from 0.9 BMI units (between the most educated Hispanic and white men) to 2.9 BMI units (between the least educated Hispanic and white women). The highest prevalence of overweight was among the least educated Hispanic women (61.1%) and Hispanic men (48.4%). The higher BMI levels of Hispanic women and men relative to their white counterparts were not explained by age, gender, education, city of residence, time of survey, or language spoken in a multiple regression model. Hispanic women and men both reported higher desired body weight (height standardized) than white women and men, indicating a possible contribution of cultural factors to the ethnic differences in overweight.These findings provide insight into the greater prevalence of overweight in Hispanic relative to white populations as well as guidance for weight-loss interventions tailored to low socioeconomic groups.

Abstract

Homeless women are a large and diverse group, constituting one fifth of the US homeless adult population. Although most homeless women do not have major mental illness, homeless women exhibit disproportionately high rates of major mental disorders and other mental problems. Rates of mental disorders are highest among whites and women without children, and important variations by subgroups of homeless women reinforce the need for disaggregated analysis. Many homeless women with serious mental illness are not receiving needed care, apparently due in part to the lack of perception of a mental health problem and the lack of services designed to meet the special needs of homeless women.

Abstract

DATA ARE PRESENTED for 933 Hispanic and 7087 white men and women, ages 25 to 74, who participated in biennial cross-sectional surveys in California from 1979 to 1990. Using an unadjusted analysis, white women and men had significantly higher mean systolic blood pressures (123.4 mmHg versus 119.6 mmHg) and higher levels of hypertension (29.0% versus 22.9%) than Hispanic women and men (P values greater than 0.001). To reduce bias from confounding, a subset of 702 Hispanics were matched to 702 whites on age, gender, education, city of residence, and time of survey. All ethnic differences in blood pressure became nonsignificant in this analysis. The mean systolic blood pressure for whites was 120.0 mmHg; for Hispanics, 120.7 mmHg (24.4% hypertension for both groups, P values greater than 0.10). These findings show the importance of taking sociodemographic factors into account when examining ethnic differences in blood pressure.

Abstract

In the past two decades several community intervention studies designed to lower the risk of cardiovascular disease in populations have been completed. These trials shared the rationale that the community approach was the best way to address the large population attributable risk of mild elevations of multiple risk factors, the interrelation of several health behaviors, and the potential efficiency of large-scale interventions not limited to the medical care system. These trials also shared several threats to internal validity, especially the small number of intervention units (usually cities) that could be studied. The purpose of this paper is to reflect on the lessons learned in one of the studies, the Stanford Five-City Project, which began in 1978. The anticipated advantages were observed, including the generalizability of the intervention components, the potential for amplification of interventions through diffusion in the community, and the efficiency of the mass media and other community programs for reaching the entire population. Numerous components of the intervention proved effective when evaluated individually, as was true in other community studies. However, the design limitations proved difficult to overcome, especially in the face of unexpectedly large, favorable risk factor changes in control sites. As a result, definitive conclusions about the overall effectiveness of the communitywide efforts were not always possible. Nevertheless, in aggregate, these studies support the effectiveness of communitywide health promotion, and investigators in the field should turn to different questions. The authors have learned how little they know of the determinants of population-level change and the characteristics that separate communities that change quickly in response to general health information from those that do not. Future studies in communities must elucidate these characteristics, while improving the effectiveness of educational interventions and expanding the role of environmental and health policy components of health promotion.

Abstract

During the 1980s extensive local and national cardiovascular health promotion campaigns were implemented to improve knowledge of risk reduction. This study analyzed changes from 1980 to 1990 in knowledge of acquired cardiovascular risk factors (i.e., actual, objective knowledge of adverse lifestyle factors affecting cardiovascular health); perceived knowledge of risk-reduction strategies (i.e., subjective knowledge about how to reduce the likelihood of cardiovascular disease); and interest in risk modification (i.e., interest in changing risk-factor habits) by socioeconomic status using level of education. The study population included 2,455 women and men 25-74 years of age from three population-based cross-sectional surveys in two northern California cities. We found significant differentials in baseline knowledge that widened over the 10-year study period, resulting in larger disparities across educational groups at the final survey in 1990 (P < .05). From 1980 to 1990, individuals with < 12 years of education experienced only slight improvement in their knowledge of cardiovascular risk factors (mean summary score of 4.4 increasing to 5.5, based on a 17-item questionnaire of risk factors); those with > or = 16 years of education experienced twice as much improvement (mean of 8.4 increasing to 11.1) (P < .05). There were similar time-effect disparities in knowledge of risk-reduction strategies (P < .05). In contrast, interest in risk modification was high for all educational groups and remained uniform across time. The continuing and widening disparity in knowledge between socioeconomic groups suggests the need for policymakers to reform existing cardiovascular risk-reduction education campaigns.

Abstract

Although past studies have compared cigarette smoking patterns in Hispanics and whites, few have examined differences within sex and educational subgroups. Data are presented for 1,088 Hispanic women and men (89% Mexican-American origin) and pairwise matched white women and men (544 pairs), aged 25-74 years, who participated in population-based cross-sectional surveys in California in 1979-1990. Each pair was matched on age, sex, educational level, city of residence, and survey time period. There were large differences in smoking prevalence rates between Hispanic and white pairs with low educational attainment. White women and men with less than a high school education were approximately twice as likely to be current daily cigarette smokers as were similarly educated Hispanic women and men (46.1 vs. 20.6% for women and 52.7 vs. 30.1% for men). As the level of education increased, these ethnic differences in smoking decreased and became negligible among those who completed college. Virtually all low-educated white men (92.5%) and most low-educated white women (73.1%) were either current or former daily smokers. There were large ethnic differences in rates of smoking cessation advice from a physician; only 8.3% of low-educated Hispanic men who were current daily smokers had ever been advised by a physician to stop smoking, compared with 59.6% of low-educated white men. These data confirm ethnic differences in smoking behavior and identify the high smoking rates of white men and women with low educational attainment, thus delineating an often unrecognized group toward whom tobacco prevention and cessation activities should be directed.

Abstract

The objective of this study was to determine the effects of age and life-style factors on body mass index (BMI) in a longitudinal, community-based sample. A total of 568 men and 668 women (20-60 years of age) were randomly chosen from four Northern California communities and followed for up to 7 years. Age, sex, marital status, smoking status, hours of television watched, frequency of consumption of several food items, and physical activity were used to predict rate of change of body mass index (BMI-slope). BMI increased the most for both sexes through at least age 54. The BMI-slope was higher for women compared with men, and for smokers who stopped compared with those who never smoked or continued to smoke during the study. The BMI-slopes were lower for individuals who increased activity. Other life-style variables had weak or inconsistent effects on the BMI-slope. We conclude that the BMI-slope increases over age for both sexes and that increased physical activity may reduce the BMI-slope.

Abstract

This comparative study tests for ethnic differences in dietary fat consumption in a community-based sample of Hispanic and white adults with low educational attainment (< 12 years of schooling) and a separate sample of their children.Data are presented for adults (age 20-64, n = 886) and youths (age 12-19, n = 170) from four California cities who participated in one of four sequential cross-sectional surveys (1981-1990).After adjustment for age, sex, city of residence, and time of survey, white adults were significantly (P < 0.03) more likely than Hispanic adults to have eaten high-fat foods in the last 24 hr, such as red meat (75.7% vs 68.4%), cured meats, (39.1% vs 25.8%), and cheese (41.4% vs 32.7%). Furthermore, white adults consumed significantly (P < 0.001) more fat, as measured by percentage of calories from total fat (37.7% vs 33.3%) and saturated fat (13.7% vs 11.8%), and consumed significantly less dietary carbohydrate (45.5% vs 49.7%) and fiber (17.1 g vs 26.0 g) than Hispanic adults. Ethnic differences were similar for the youth sample (except for carbohydrates), but were generally not significant. A graded relationship was found between acculturation and dietary measures, where more acculturated Hispanics (English-speaking) were intermediate between less acculturated Hispanics (Spanish-speaking) and whites in their dietary intake.This study illustrates the high dietary fat consumption of whites with low educational attainment, the increasing fat consumption of Hispanics at higher levels of acculturation, and the need for effective dietary interventions for low educated whites and Hispanics.

Abstract

This paper presents a prospective examination of sociodemographic, psychosocial, and physiologic characteristics associated with positive change in cardiovascular disease risk factors during a 6-year multiple risk factor intervention study.Data are presented on 221 women and 190 men (aged 25 through 74 years) who participated in four cohort surveys (1979 through 1985). A signal detection model was used to identify baseline variables that best divide the sample into subgroups on the basis of the probability of positive change in a composite risk factor score.Sixty-nine percent of the respondents showed a positive change in risk factor score during the intervention. The subgroup with the highest proportion of positive changers (83%) was composed of older adults (> 55 years) with the highest perceived risk, highest health media use, and highest blood pressure and cholesterol levels. The subgroup with the lowest proportion of positive changers (42%) was the least educated, was the most likely to be Hispanic, and had the lowest health knowledge and self-efficacy scores.The differing composition of subgroups who respond or do not respond to community cardiovascular disease interventions illustrates the need to develop specific interventions that target different age, socioeconomic, and cultural subgroups.

Abstract

Using data from two cross-sectional surveys, we examine how homeless adults living with children differ in sociodemographic characteristics, adverse childhood experiences, and addictive and psychiatric disorders from homeless adults who are not living with children. The surveys were conducted in late 1989 and early 1990 in Santa Clara County, California. Women (n = 100) and men (n = 41) with children were sampled from the two largest family shelters in the County (94% response rate); women (n = 169) and men (n = 1268) without children were sampled from the three main adult shelters in the County (98% response rate). Adults with children (especially women) were significantly younger, less educated, less likely to have experienced full-time employment, and more likely to have been supported by public assistance before first becoming homeless than adults without children. In addition, adults with children became homeless at younger ages, had been homeless for less time, and were less likely to experience multiple episodes of homelessness. Further differences were found for addictive and psychiatric disorders--adults with children were significantly less likely to enter homelessness with histories of excessive alcohol intake (both men and women) and psychiatric hospitalizations (women only) than adults without children. The distinct risk factor profile of homeless adults living with children renders them a critically important demographic group on which to focus new public health programs and social strategies.

Abstract

Although past studies have compared health-related risk factors in Hispanics and whites, few studies have controlled for potential confounding from sociodemographic variables. Using data on men and women aged 25-74 years who responded to biennial cross-sectional surveys conducted in four diverse California cities from 1979 to 1990, the authors employed a matched-pairs design in which 756 Hispanic respondents were matched to 756 white respondents according to age, sex, educational level, city of residence, and time of survey. No significant differences between Hispanics and whites were found for any of the blood pressure indicators (systolic and diastolic blood pressure, prevalence of hypertension, and use of antihypertensive medication), caloric intake, total cholesterol, alcohol intake, or physical activity. The only variables for which Hispanics had higher levels of risk factors than whites were body mass index (weight (kg)/weight (m)2; 27.5 vs. 25.6, p < 0.001) and high density lipoprotein cholesterol (48.6 mg/dl vs. 50.1 mg/dl, p < 0.03). Whites, on the other hand, were significantly more likely to be current smokers than Hispanics (34.2% vs. 24.0%, p < 0.001) and, among smokers, to smoke a greater number of cigarettes per day (19.7 vs. 11.4 cigarettes/day, p < 0.001). Whites were also significantly more likely to have higher-fat diets, as measured by percentages of calories derived from total fat (37.6% vs. 35.1%, p < 0.04) and saturated fat (13.6% vs. 12.3%, p < 0.03). Examination of interactions indicated further risk factor differences by ethnicity across several sex, age, and educational subgroups.

Abstract

The Stanford Five-City Project was initiated in 1978 to evaluate the effects of community-wide health education on coronary heart disease risk factors in two control (San Luis Obispo and Modesto) and two treatment (Monterey and Salinas) cities. This paper examines sex differences in the prevalence of smoking, hypercholesterolemia, and hypertension from the baseline survey in 1979-1980 through the conclusion of the intervention in 1985-1986. Four independent cross-sectional surveys (n = 1,713, 1,709, 1,848, and 1,768) and four repeated surveys of a cohort (n = 817) were conducted. This analysis presents findings separately for a younger age group (25-49 years) and an older age group (50-74 years). Smoking, hypercholesterolemia, and hypertension were more prevalent among younger men than younger women in both treatment and control cities. In general, this excess risk among younger men disappeared or reversed in the older age group. Over the 7-year study, the prevalence of hypertension and smoking decreased for both men and women in all surveys, the prevalence of hyper-cholesterolemia displayed no definite change, and male/female ratios of risk factor prevalence showed either no change or a slight decrease. This study confirms a higher prevalence of the three major risk factors for coronary heart disease among younger men, with the prevalence of hypercholesterolemia and, to a lesser extent, the prevalence of smoking becoming greater among women than men in the older age group and the prevalence of hypertension becoming equivalent.

Abstract

This paper examines the effects of community-wide health education on diet-related knowledge and behavior and on plasma cholesterol levels during an experimental field study in medium-sized cities in northern California. Samples of the population aged 12-74 years were drawn at baseline and every 2 years thereafter to obtain four cross-sectional surveys; participants aged 25-74 years are included in this paper (n = 6,814 or about 425 per city per survey). The baseline sample was asked to return to three follow-up surveys, also 2 years apart, constituting the cohort survey sample (n = 777). Diet was assessed by 24-hour recalls. In the serial cross-sectional survey samples, nutritional knowledge increased over time in both men and women in all cities; among women, this increase was significantly greater in the treatment cities. Plasma cholesterol declined significantly only in men and in neither sex was there evidence of a larger decline in treatment than in control cities. Dietary saturated fat intake tended to decline, but not significantly in either sex, and there was no evidence of treatment impact. Dietary cholesterol intake declined in both sexes. Results in the cohort samples were similar, except plasma cholesterol levels were unchanged over time in men and increased in women, and dietary saturated fat intake declined significantly among women. Secular improvements in knowledge of nutrition and in dietary cholesterol intake occurred during the early 1980s in both men and women in these four cities, while there was less consistent improvement in dietary saturated fat intake. Only nutritional knowledge among women achieved greater improvement in treatment cities than in control cities. Continued and greater change in nutrition probably requires more sustained effort and broader methods, including changes in the food supply.

Abstract

This article examines cholesterol-related knowledge, cholesterol-related behaviors, and plasma cholesterol levels in 12-24-year-olds, using data collected from four community-based cross-sectional surveys conducted 1979-1980, 1981-1982, 1985-1986, and 1989-1990. Participants included 1,552 individuals from randomly sampled households in two control cities (San Luis Obispo and Modesto, California) of the Stanford Five-City Project. Over the eleven-year study period, cholesterol-related knowledge improved in both control cities (P < .0002). Cholesterol-related behavior (P < .0003) and plasma cholesterol levels (P < .002) significantly improved only in San Luis Obispo (a college city with more 19-24-year-olds and a better-educated population than Modesto). In general, knowledge and behavior scores and plasma cholesterol levels were lower in these 12-24-year-olds than in 25-74-year-olds, although trends at all ages were similar over time and by demographic variables. Although the cholesterol-related interventions that began in the mid-1980s primarily targeted adults, these 12-24-year-olds' cholesterol-related knowledge improved (as did, to a lesser extent, their cholesterol-related behavior and plasma cholesterol levels). These findings have implications for upcoming youth-related cholesterol interventions.

Abstract

Data on smoking prevalence from four cross-sectional community-based surveys (1979-1990) are presented for 2,605 adolescents and young adults 12-24 years of age.The surveys were conducted in two treatment and two control cities in Northern California as part of the Stanford Five-City Project, a multifactor cardiovascular disease prevention study.Over the 12-year study period, prevalence of daily smoking declined in all cities by approximately 50% among 16- to 19- and 20- to 24-year-olds but showed little change among those 12-15 years old. Although the declines were especially large in the two treatment cities and in one control city, the declines in treatment cities were not significantly different from those in control cities. During each period, smoking prevalence escalated most sharply between the ages of 12-15 and 16-19, the period of development when students advanced from junior high to high school.Despite impressive secular declines, it appears that the Five-City Project community intervention, which targeted smoking in adults, did not have a diffusion effect on the tobacco use habits of adolescents.

Abstract

A cross-sectional survey of 1,431 homeless adults was conducted during the winter of 1989-90 at three shelters in Santa Clara County, CA, with a 98 percent response rate. Of the 1,008 U.S.-born men, 423, or 42 percent, were veterans, including 173 combat-exposed veterans and 250 noncombat-exposed veterans. There were 585 nonveterans. Both combat and noncombat-exposed veterans were significantly more likely to report excessive alcohol consumption before their initial loss of shelter than were nonveterans. Combat-exposed veterans had the highest prevalences of psychiatric hospitalizations and physical injuries before homelessness, 1.5 to 2 times higher than nonveterans and noncombat-exposed veterans. The length of time between military discharge and initial loss of shelter was longer than a decade for 76 percent of combat-exposed veterans and 50 percent of noncombat-exposed veterans. The extended time from discharge to homelessness suggests that higher prevalences of alcohol consumption, psychiatric hospitalization, and physical injury among veterans, especially those exposed to combat, may not have arisen from military service. It is possible, however, that such disorders may be considerably delayed before becoming serious enough to impact one's family, work, and the availability of shelter.

Abstract

In 1989 through 1990, we conducted a cross-sectional survey of 1437 homeless adults in northern California (98% response rate). Prevalences of alcohol abuse, illegal drug use, and psychiatric hospitalization when adults first became homeless were 15% to 33% lower than prevalences following homelessness. The largest differences between the homeless and a comparison group of 3122 nonhomeless adults were for psychiatric hospitalization (odds ratios [ORs] of 4.6 for men and 5.9 for women) and alcohol abuse (ORs of 2.3 for men and 4.0 for women). However, when prehomeless prevalences of addictive and psychiatric disorders were compared with prevalences among the nonhomeless, absolute differences were no greater than 12%.

Abstract

A cross-sectional study compared characteristics of homeless adults with and without substance abuse, physical health problems, and history of psychiatric hospitalization when they first became homeless. Self-report data on demographic characteristics, adverse events in childhood, and history of medical disorders were collected from 1,399 homeless adults who used three shelters in Santa Clara County, California, during a five-month winter period in 1989 and 1990 (96 percent response rate). A total of 45.6 percent of the respondents reported no impairments when they first became homeless. They were distinguished from those with impairments at onset of homelessness by their younger age, minority status, lower educational attainment, and lower frequency of adverse events in childhood. Respondents who reported no impairments when they first became homeless were likely to develop addictive and psychiatric disorders over time. Those who had been homeless five years or more reported high rates of alcohol abuse (34.5 percent), illegal drug use (24.1 percent), and psychiatric hospitalization (20.7 percent).

Abstract

To determine whether cholesterol-related knowledge and behavior and plasma cholesterol levels were stable until the inception of large-scale national interventions in the middle to late 1980s, whether they subsequently improved, and whether these levels varied by subgroups.Data were collected from 4173 adults aged 25 through 74 years in the two control cities (San Luis Obispo and Modesto, Calif) of the Stanford Five-City Project. Five separate, community-based surveys were conducted in 1979-1980, 1981-1982, 1983-1984, 1985-1986, and 1989-1990.Cholesterol-related knowledge and behavior and plasma cholesterol levels improved (P = .0001) in both cities after the early 1980s. Those who were more educated, female, older, or nonsmokers had significantly higher knowledge and behavior scores, and those who were younger, more educated, or normotensive had significantly lower plasma cholesterol levels.Improvements in this population's cholesterol-related knowledge and behavior and plasma cholesterol levels began in 1985-1986, suggesting that the extensive cholesterol interventions that began in the middle 1980s in the United States created positive cholesterol-related changes at the community level.

Abstract

Trends in blood pressure, smoking, and cholesterol were examined from 1979-1980 through 1985-1986 in four cities in California by level of education (< high school, high school graduate, some college, college or postgraduate).Four biennial cross-sectional surveys (n = 6,580) were conducted in two treatment and two control cities to evaluate a 6-year community health education intervention, conducted as part of the Stanford Five-City Project.Over the 8-year study period, men and women ages 25-74 from each educational group in the treatment cities showed significant declines in smoking prevalence and levels of blood pressure and cholesterol (with the exception of cholesterol in women). In general, declines in the least educated group (< high school) were stronger than declines in the most educated group (college or postgraduate). Similar declines occurred in each educational group in control cities.These results illustrate that persons from all educational levels can modify their risk for CVD and are of particular importance because of the higher prevalence of CVD risk factors among those with less education. The similarity of time trends in treatment as well as control cities suggests that the broad-based, multisource health education efforts in the United States are succeeding across the educational spectrum.

Abstract

In this study we tested the association between occupational stress--as measured by job demands, decision latitude, and job strain--and hypertension in a population of 1396 Black and White bus drivers.Height, weight, blood pressure, and medical history were assessed by physical exam. Drivers completed a questionnaire assessing their work schedules, personal habits, and self-perceptions about job demands and decision latitude.Univariate analyses revealed significant inverse associations; lower levels of job demands and job strain were associated with a higher prevalence of hypertension for Blacks and Whites. After 12 confounding variables were controlled for, the association between these two measures of occupational stress and hypertension became nonsignificant. Decision latitude was also not significantly associated with hypertension.Our findings are inconsistent with previous studies' findings of a positive association between job strain and chronic diseases. The difference in results may be explained by our incorporation of individuals' perceptions in the measurement of occupational stressors and our use of individuals from a single occupation with comparable job responsibilities and income, thus controlling for potential confounding by social class.

Abstract

The detection of semen on the skin of children who present within 72 hours of an episode of sexual assault is critical to medical, forensic, and legal personnel. The Wood's Lamp, a UV light that causes semen to fluoresce, and four forensic laboratory techniques were compared to determine their sensitivity and decline in sensitivity over time.A descriptive study.Eleven adult female volunteers.Semen was placed on the skin of the volunteers. Samples of the dried semen were assessed during a 28-hour period with the Wood's Lamp, microscopy, the acid phosphatase assay, and two assays for the prostatic protein p30 (counterimmunoelectrophoresis and enzyme-linked immunosorbent assay). The intensity of the Wood's Lamp fluorescence of semen diminished dramatically by 28 hours; in contrast, the fluorescence of urine persisted up to 80 hours. Over time, the p30-enzyme-linked immunosorbent assay technique was more sensitive than microscopy, the acid phosphatase assay, and p30-counterimmunoelectrophoresis in detecting semen on skin.The Wood's Lamp is not a sensitive screening tool and should be used with caution. To improve the detection of sexual abuse in children, we recommend that the p30-enzyme-linked immunosorbent assay be used because of its potential as a more sensitive assay than those in current clinical use.

Abstract

This cross-sectional study, conducted in 1988, examines the association between hemoglobin level and behavior problems in 236 Hispanic children, ages 2 to 5 years, residing in low-income census tracts in the Los Angeles area. Venous blood samples were analyzed for hemoglobin, mean corpuscular volume, free erythrocyte protoporphyrin, and lead. Family and child data were obtained through a home interview with the child's mother or guardian. Behavior problems were assessed using questionnaires modeled after Child Behavior Checklists for children ages 2 to 3 and 4 to 5 years. A significant correlation between decreasing hemoglobin values and increasing total behavior problems scores was found for girls, 2 to 3 and 4 to 5 years old. These associations remained significant in both age groups after adjusting for maternal education and marital status. Statistically significant inverse correlations also were found between hemoglobin and social withdrawal, sleep problems, and depression (internalizing subscale behaviors) in 2- to 3-year-old girls, and between hemoglobin and aggression and hyperactivity (externalizing subscale behaviors) in 4- to 5-year-old girls. The potentially negative consequences of these anemia-related behavior problems on children's development, learning ability, and parent-child relationships warrant further investigation.

Abstract

Socioeconomic status (SES) is usually measured by determining education, income, occupation, or a composite of these dimensions. Although education is the most commonly used measure of SES in epidemiological studies, no investigators in the United States have conducted an empirical analysis quantifying the relative impact of each separate dimension of SES on risk factors for disease.Using data on 2380 participants from the Stanford Five-City Project (85% White, non-Hispanic), we examined the independent contribution of education, income, and occupation to a set of cardiovascular disease risk factors (cigarette smoking, systolic and diastolic blood pressure, and total and high-density lipoprotein cholesterol).The relationship between these SES measures and risk factors was strongest and most consistent for education, showing higher risk associated with lower levels of education. Using a forward selection model that allowed for inclusion of all three SES measures after adjustment for age and time of survey, education was the only measure that was significantly associated with the risk factors (P less than .05).If economics or time dictate that a single parameter of SES be chosen and if the research hypothesis does not dictate otherwise, higher education may be the best SES predictor of good health.

Abstract

Although more than 2 million US children are in self-care after school, little is known of the extent to which self-care may adversely affect developmental processes, such as the development of self-esteem. To test the hypothesis that lower self-esteem is associated with being in self-care, 297 subjects in fourth and sixth grades from three ethnically diverse schools in northern California were enrolled in a cross-sectional study during November 1987. Sixty percent of subjects were in adult in-home care, 13% in adult out-of-home care, 19% in self-care, and 8.0% in older sibling care. No significant differences in self-competence scores, as measured by the Harter Self-perception Profile for Children, were observed for children in self-care compared with the three other care groups. However, children who were cared for by older siblings unexpectedly exhibited lower self-competence scores for five of the six self-competence domains, with three domains showing significance at P less than .05. Children in self-care were significantly more isolated socially than children in adult care, reporting fewer opportunities to play outside or have friends visit at their homes. The results indicate that children in sibling care may be at potentially greater risk for negative effects on self-esteem and social development. Children in self-care may also experience more social isolation after school than children in other forms of afterschool care.

Abstract

To determine the percentage of smokers reporting that a physician had ever advised them to smoke less or to stop smoking, and the effect of time, demographics, medical history, and cigarette dependence on the likelihood that respondents would state that a physician had ever advised them to stop smoking.Data were collected from the Stanford Five-City Project, a communitywide health education intervention program. The two treatment and three control cities were located in northern and central California. As there was no significant difference between treatment and control cities regarding cessation advice, data were pooled for these analyses.There were five cross-sectional, population-based Five-City Project surveys (conducted in 1979-1980, 1981-1982, 1983-1984, 1985-1986, and 1989-1990); these surveys randomly sampled households and included all residents aged 12 to 74 years.Improved smoking advice rates over time in all towns was an a priori hypothesis.Of the 2710 current smokers, 48.8% stated that their physicians had ever advised them to smoke less or stop smoking. Respondents were more likely to have been so advised if they smoked more cigarettes per day, were surveyed later in the decade, had more office visits in the last year, or were older. In 1979-1980, 44.1% of smokers stated that they had ever been advised to smoke less or to quit by a physician, vs 49.8% of smokers in 1989-1990 (P less than .07). Only 3.6% of 1672 ex-smokers stated that their physicians had helped them to quit.These findings suggest that physicians still need to increase smoking cessation counseling to all patients, particularly adolescents and other young smokers, minorities, and those without cigarette-related disease.

Abstract

Past work suggests that stressful life events and social support are significantly associated with a broad range of child health outcomes. Such associations have remained, however, generally modest in magnitude, suggesting that stress and support may be only proxy measures for a deeper, more central aspect of childhood psychosocial experience. One aspect of young people's lives that could plausibly mediate the effects of stress and social support on health is the sense of stability and "permanence" in ongoing life experience. We developed a standardized psychometric instrument for measuring a "sense of permanence" and employed the measure in a prospective 1-year study of health outcomes among 89 adolescent mothers and their infants. Psychosocial and demographic factors were significantly predictive of maternal, but not infant, health outcomes, and the sense of permanence appeared to operate as a "final common pathway" in the influence of psychosocial variables on health and illness end points. Results of the study underscore the importance of continuity and stability in childhood and suggest that changes in an individual's sense of permanence may underlie the previously documented health effects of stressful life events and social support.

Abstract

To investigate the extent to which individuals use health education resources for cardiovascular risk reduction, we conducted a cross-sectional survey of 2,234 adults 18-74 years of age in four northern California cities. The purposes of the study were to (1) assess the use of 10 cardiovascular disease (CVD) intervention materials and programs, (2) compare use rates between the treatment and control communities of the Stanford Five-City Project, and (3) examine variation in use by type of intervention, risk factor, and sociodemographic status. The community level analyses indicate that up to one-third of adults had used interventions to modify CVD risk factors during a one-year period, and that communities with comprehensive risk reduction programs had higher rates of use, particularly for printed education materials. The subgroup analyses indicate substantial variability in use depending on sociodemographic status, with those at highest risk (men, older adults, and low socioeconomic groups) reporting the lowest use of CVD intervention materials and programs.

Abstract

The impact of providing home care for ventilator-dependent children was studied in a cross-sectional survey of 18 northern California families. Through the use of a confidential structured interview and the impact on Family Scale, we obtained information on family demographics; the childrens' medical conditions; financial, social, and personal impact on the family; and parental coping-mastery of the care of a ventilator-dependent child at home. Analysis of scores from the impact on Family Scale showed no differences in the perceived family impact between primary caretakers and their spouses. Primary caretakers in the sample, however, showed significantly reduced Coping subscale scores with a longer duration of home ventilatory care. This finding, if confirmed in future studies, has policy implications for physicians and other health professionals working with ventilator-dependent children and their families, especially those who care for children over long periods.

Abstract

The Stanford Five-City Project was initiated in 1978 to evaluate the effects of a community-wide health education program on cardiovascular risk factors, including blood pressure. Two treatment cities received an education program, which used the mass media, various community-based programs, and health professionals, designed to encourage individuals to learn their blood pressure levels, stay in the care of a physician if hypertensive, achieve ideal weight, exercise regularly, and reduce dietary sodium. Physicians were encouraged to follow national hypertension treatment guidelines and were provided with a range of patient education materials. To evaluate the effect of the intervention on cardiovascular risk factors, four independent cross-sectional surveys of randomly selected households and four repeated surveys of a cohort were conducted in both treatment cities and in two of the three control cities. After 5-1/3 years of intervention, blood pressure in the treatment cities exhibited an overall decline of 7.4 and 5.5 mmHg systolic and 5.0 and 3.7 mmHg diastolic in the cohort and independent surveys, respectively. These declines produced net changes between the treatment and control cities ranging from -1.1 to -3.8 mmHg. While the magnitude of these changes is not large, the results are significant from a public health perspective because they reflect changes in the overall community.

Abstract

This cross-sectional survey was undertaken to examine whether the homeless poor have a higher prevalence of risk factors for ill health than the nonhomeless poor. Seventy-one adults in four age groups who attended a free-meal program in northern California were recruited during a 1-month period in 1987. The majority of the respondents lived on the streets, in vehicles, or in substandard housing located in an area undergoing rapid urban redevelopment. Regardless of employment or government assistance, the income of 100 percent of the respondents fell below the Federal poverty level. Overall, the sociodemographic profile of the study population was remarkably similar to that of the general population of California adults. Sixty-six percent had completed high school, 78 per cent had lived in the city for 5 or more years and, at most, 23 percent reported serious alcohol or emotional problems. When compared with the nonhomeless poor, the homeless poor were slightly less educated, more mobile, and more likely to report alcohol and emotional problems. Larger differences were evident for health-related variables, with the homeless poor being significantly less likely to have health insurance coverage, to receive preventive health care, and to be nonsmokers than the nonhomeless poor (P values less than .05). There were also large differences in access to heated rooms, running hot water, and cooking facilities, with approximately 90 percent of the homeless poor reporting no access to these fundamental necessities.

Abstract

This article examines the associations between education, a primary indicator of social class, and six risk factors for disease. Data are presented on a sample of 3,349 individuals ages 25-74 years who participated in one of four cross-sectional surveys conducted by the Stanford Five-City Project between 1979 and 1986. The six risk factors examined are knowledge about health, cigarette smoking, hypertension, serum cholesterol, body mass index, and height. A highly significant pattern of associations was found between education level and the six risk factors, in the direction of higher risk among those with lower education (all P values less than 0.01). These associations persisted for both sexes and in the younger as well as the older age groups, with the exception of cholesterol values for males and for those in the 50 to 74-year-old age group. Furthermore, all associations remained highly significant after controlling for income and occupation, two other indicators of social class. When a summary-adjusted risk score was plotted against year of survey for the five education levels, a gradient of effect was observed where each progressive education level showed a decrease in total risk score. This gradient was replicated in all four cross-sectional surveys, providing evidence for the consistency of the findings over time.

Abstract

1. To test whether prevalence of hypertension was higher among these bus drivers than among employed individuals in general, drivers were compared to three groups: individuals from both a national and local health survey and individuals undergoing baseline health exams prior to employment as bus drivers. 2. After adjustment for age and race, hypertension rates for bus drivers were significantly greater than rates for the three comparison groups. 3. These findings support previous results from international studies of bus drivers suggesting that exposure to the occupation of driving a bus may carry increased health risk.

Abstract

This study examines the extent to which a set of 10 demographic, behavioral, and medical risk factors explain black/white differences in hypertension. Data are from a cross-sectional examination of San Francisco transit drivers aged 25-65 years surveyed during 1983-1985 as part of an occupational health study. The inherent restriction of the study population to bus drivers and the further restriction to males in this population (764 blacks and 224 whites) controlled for factors related to occupation and sex. Control of 10 additional potential risk factors, including age, education, body mass index, smoking, and intake of caffeine and alcohol was possible in the analytic phase of the study. The unadjusted prevalence of hypertension (systolic blood pressure greater than or equal to 140 mmHg, diastolic blood pressure greater than or equal to 90 mmHg, or current use of antihypertensive medications) was 36.1 per cent for black males compared with 30.8 per cent for white males. The greatest difference in prevalence was observed for black males aged 55-64 years, for whom the prevalence was 46 per cent higher than for white males the same age. Despite higher rates of hypertension, blacks in all age groups exhibited lower levels of most major risk factors for hypertension. As a result, the independent effect of race on hypertension was increased rather than attenuated when the 10 covariables were taken into account (odds ratio of 1.27 in the unadjusted analysis, increasing to 1.54 in the adjusted, multivariate analysis). That this set of risk factors did not explain the higher rates of hypertension among blacks suggests that racial differences may arise from as yet unrecognized environmental and/or individual factors. The results also indicate that the association between race and blood pressure may have been underestimated in past studies that have relied on unadjusted analyses, in which negative confounding or masking effects of covariables have not been considered.

Abstract

In an extensive search of available literature, 22 epidemiological studies that have examined health risks of bus drivers were identified. These studies focus on three main disease categories: (1) cardiovascular disease, including hypertension, (2) gastrointestinal illnesses, including peptic ulcer and digestive problems, and (3) musculoskeletal problems including back and neck pain. The studies consistently report that bus drivers have higher raes of mortality, morbidity, and absence due to illness when compared to employees from a wide range of other occupational groups. Increased disease rates have been found for drivers regardless of the use of different research methodologies, measurement techniques and comparison groups. When evaluating the impact of bias on the estimates of risk, it appears likely that findings are conservative: strong systematic selective factors have probably favoured the elimination of those in poorer health both at the time of entry into and exit from the job of bus driving and other sources of bias have most likely caused underestimations of risk. Nevertheless, there remain questions that need careful assessment before firm conclusions can be made about whether increased disease rates result from driving a bus. Such questions, coupled with the consistent findings of heightened risk of disease, make urban bus drivers an appropriate and promising occupational group in which to study further the potential adverse effects of the work environment on employee health.

Abstract

This paper presents an analysis of self-reported stressors and blood pressure in a population of 1,428 San Francisco bus drivers surveyed from 1983 to 1985 as part of an occupational health study. To test the hypothesis of a positive association between psychosocial stressors and hypertension, the authors derived a stressor index from a survey instrument that assessed subjects' appraisal of work-related problems. A logistic regression analysis revealed an unexpected inverse association between the stressor index and hypertension that remained significant after adjustment for 12 potential confounding variables (standardized odds ratio = 0.84, p = 0.038). An analysis restricted to the 1,040 normotensive subjects, with mean blood pressure level as the outcome variable, also yielded inverse findings. To assess whether the results were specific to blood pressure, the authors repeated the multiple logistic analysis for gastrointestinal, respiratory, and musculoskeletal problems. In contrast to the inverse association found for hypertension, highly significant positive associations were found between the stressor index and these health problems. When prevalence of disease was examined by level of stressor score, a significant inverse gradient was observed for hypertension and significant positive gradients were observed for gastrointestinal, respiratory, and musculoskeletal problems (p values less than 0.001). An etiologic implication of these findings is that there may be a direct inverse association between subjective appraisal of stressors and blood pressure. A methodological implication is that subjective appraisal of stressors by persons with heightened blood pressure may be an invalid measure of objective, verifiable stressors.

Abstract

This paper reports the results of a cross-sectional study conducted to evaluate the prevalence of hypertension in 1500 black and white male bus drivers from a large urban transit system in the US. Data for this study were compiled from the files of an occupational health clinic which conducts biennial medical examinations for drivers' license renewal. To test whether prevalence of hypertension was higher among bus drivers than among employed individuals in general, drivers were compared to three groups: individuals from both a national and local health survey and individuals undergoing baseline health examinations prior to employment as bus drivers. After adjustment for age and race, hypertension rates for bus drivers were significantly greater than rates for each of the three comparison groups. These findings support previous results from international studies of bus drivers suggesting that exposure to the occupation of driving a bus may carry increased health risk. This research has expanded into an on-going study which has the goals of clarifying the extent of hypertension in bus drivers and identifying specific behavioural and occupational factors that may be responsible for increased risk of cardiovascular disease.

Abstract

Personal health and well-being are gaining priority on the American agenda. A renewed interest in health promotion has been facilitated by the need to contain health care costs, realization of the limits of medicine in preventing illness, and a deeply rooted societal ethic of personal responsibility for individual health. Although the health status of Americans has changed significantly for the better during this century, further improvements are necessary, especially among high risk subgroups within the population who have not been effectively reached by traditional health promotion strategies. Past efforts, aimed at individuals modifying their risk factors, have neglected to address environmental factors that contribute to disease risk. This points to the need for an integrated approach where problems are addressed as properties of the systems in which individuals behave. This paper reviews selected health trends in the United States, discusses limitations of the current approach to health promotion, presents a comprehensive definition of prevention, and provides principles for planning that may facilitate improved health status in this country.

Abstract

Little is known about pathways by which socioeconomic status (SES) translates into individual differences in cardiovascular disease (CVD) risk factors. Because the socioeconomic structure is not the same for all ethnic subgroups, the pathways that lead to the development of CVD risk factors may vary by both SES and ethnicity. We used data from a large national survey to examine the independent associations of two indicators of SES (education and income) and ethnicity with six primary CVD risk factors. We then used data on smoking that reflected a temporal sequence to examine the extent to which SES and ethnicity influenced smoking at three different time points, from smoking onset, to a serious quit attempt, to successful quitting. These analyses provide an understanding of the relationships between SES, ethnicity, and CVD risk factors and suggest that if the timing, focus, and content of intervention programs take pathways into account they will result in more successful outcomes.